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Search results for "Error Reporting and Analysis"
Journal Article > Study
The impact of interruptions on the duration of nursing interventions: a direct observation study in an academic emergency department.
Cole G, Stefanus D, Gardner H, Levy MJ, Klein EY. BMJ Qual Saf. 2016;25:457-465.
Interruptions are inevitable in the clinical environment, and they have been linked to an increased risk of diagnostic errors by radiologists and medication administration errors by nurses. However, the effects of interruptions are not predictable and many interruptions are essential for proper patient care. Recognizing this, commentators have called for research to analyze the causes and effects of interruptions, rather than attempting to categorically prevent interruptions. This study, conducted in an academic emergency department, contributes to our understanding of how interruptions influence patient care by examining the effect of interruptions on several specific nursing tasks. Interventions that were interrupted took longer than uninterrupted tasks, and interruptions were a significant contributor to overall nursing workload. Patients and families were the most frequent source of interruptions, demonstrating that simply implementing interventions to prevent interruptions could cause unintended consequences. The state of patient safety in the emergency department, including the role of interruptions, is discussed in a past AHRQ WebM&M perspective.
Cases & Commentaries
- Web M&M
Robert J. Weber, PharmD, MS; February 2010
An elderly woman presented to the emergency department following a hip fracture. Although the patient's medication bottles were used to generate a medication list, one of the dosages was transcribed incorrectly. Because the patient then received four times her regular dose, her surgery was delayed due to cardiac side effects.