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Search results for "Interruptions and distractions"

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  • Interruptions and distractions
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Cases & Commentaries

Air on the Side of Caution

  • Web M&M

Jamie M. Robertson, PhD, MPH, and Charles N. Pozner, MD; April 2018

A clinical team decided to use a radial artery approach for cardiac catheterization in a woman with morbid obesity. It took multiple attempts to access her radial artery. After catheter insertion, she experienced pain and pressure in her arm and chest. Review of the angiogram demonstrated the presence of an air embolism in the left coronary artery, introduced during the catheter insertion. Due to the difficulty of the procedure, the technician had failed to hold the syringe at the proper angle and introduced an air bubble into the patient's vessel.

Journal Article > Study

Task errors by emergency physicians are associated with interruptions, multitasking, fatigue and working memory capacity: a prospective, direct observation study.

Westbrook JI, Raban MZ, Walter SR, Douglas H. BMJ Qual Saf. 2018 Jan 9; [Epub ahead of print].

This direct observation study of emergency physicians found that interruptions, multitasking, and poor sleep were associated with making more medication prescribing errors. These results add to the evidence that clinical environments prone to interruptions may pose a safety risk.

Journal Article > Study

Night-time communication at Stanford University Hospital: perceptions, reality and solutions.

Sun AJ, Wang L, Go M, Eggers Z, Deng R, Maggio P, Shieh L. BMJ Qual Saf. 2018;27:156-162.

Interruptions can lead to errors, particularly when providers are sleep deprived. This retrospective cross-sectional study of pages sent to overnight general surgery and internal medicine physicians found that 27.7% were nonurgent. The authors assert that nonurgent paging contributes to alarm fatigue and suggest potential solutions.

Journal Article > Review

Technological distractions—part 1 and part 2.

Kane-Gill SL, O'Connor MF, Rothschild JM, et al; Society for Critical Care Medicine Alarm and Alert Fatigue Task Force. Crit Care Med. 2017;45:1481-1488, 2018;46:130-137.

These paired systematic reviews examined alert fatigue in the intensive care unit. The first systematic review found several strategies to reduce alerts including prioritizing alerts, developing multipart rules instead of simple alerts, and customizing commercial platforms with end-user input. The second systematic review found that alarm best practices from high reliability industries are not adhered to in intensive care unit settings.

Journal Article > Review

Intervening in interruptions: what exactly is the risk we are trying to manage?

Gao J, Rae AJ, Dekker SWA. J Patient Saf. 2017 Sep 25; [Epub ahead of print].

Interruptions can contribute to medication errors, but efforts to reduce interruptions may result in unintended consequences. The authors suggest that designing interventions around high reliability and resilience principles can address risks and increase the likelihood of lasting improvements.

Cases & Commentaries

The Forgotten Radiographic Read

  • Web M&M

Clinton J. Coil, MD, MPH, and Mallory D. Witt, MD; September 2017

A woman developed sudden nausea and abdominal distension after undergoing inferior mesenteric artery stenting. The overnight intern forgot to follow up on her abdominal radiograph, which resulted in a critical delay in diagnosing acute mesenteric artery dissection and bowel infarction.

Press Release/Announcement

ISMP Survey on Texting Medical Orders.

Institute for Safe Medication Practices.

Texting as a communication method in the clinical environment is convenient, but it introduces distraction that can result in error. This survey seeks to track the prevalence of medical order texting to better understand its impact on care processes. 

Journal Article > Commentary

Distractions in the anesthesia work environment: impact on patient safety? Report of a meeting sponsored by the Anesthesia Patient Safety Foundation.

van Pelt M, Weinger MB. Anesth Analg. 2017 Jun 9; [Epub ahead of print].

Distractions and interruptions are prevalent in health care delivery. This conference report reviews types of distractions in anesthesiology, their likelihood to introduce significant risks into care processes, and strategies to help manage distractions.

Patient Safety Primers

Nursing and Patient Safety

Nurses play a critical role in patient safety through their constant presence at patient's bedside. However, staffing issues and suboptimal working conditions can impede nurses' ability to detect and prevent adverse events.

Journal Article > Study

The impact of interruptions on medication errors in hospitals: an observational study of nurses.

Johnson M, Sanchez P, Langdon R, et al. J Nurs Manag. 2017;25:498-507.

Interruptions in nursing care are common and can contribute to errors. In keeping with prior research, this observational study of nurses found that interruptions in medication preparation and administration can compromise patient safety.

Journal Article > Study

Impact of interruptions, distractions, and cognitive load on procedure failures and medication administration errors.

Thomas L, Donohue-Porter P, Stein Fishbein J. J Nurs Care Qual. 2017;32:309-317.

Interruptions and distractions can contribute to medication administration errors. This direct observation study found that interruptions and distractions are frequent during nursing medication administration, which increased cognitive load. These results demonstrate how interruptions affect nursing safety.

Journal Article > Study

Nursing interruptions in a trauma intensive care unit: a prospective observational study.

Craker NC, Myers RA, Eid J, et al. J Nurs Adm. 2017;47:205-211.

Interruptions are a known patient safety hazard. This direct observation study demonstrated that intensive care unit nurses were interrupted about every 20 minutes. Interruptions by physicians were of longer duration and were more likely to result in the nurse moving to another activity. The authors conclude that further study is needed to determine the clinical significance of interruptions in the intensive care unit setting.

Journal Article > Study

Effectiveness of a 'Do not interrupt' bundled intervention to reduce interruptions during medication administration: a cluster randomised controlled feasibility study.

  • Classic

Westbrook JI, Li L, Hooper TD, Raban MZ, Middleton S, Lehnbom EC. BMJ Qual Saf. 2017;26:734-742.

This randomized controlled trial had nurses on four hospital wards wear "do not interrupt" vests during medication administration. The rate of interruptions the intervention nurses experienced was compared to the rate in four control wards that did not have nurses wear vests. Although the intervention reduced non–medication-related interruptions, nurses reported that the vests were time consuming and uncomfortable; less than half would support continuing the intervention. This study demonstrates the need to design and test sustainable interventions to improve patient safety.

Journal Article > Study

Ordering interruptions in a tertiary care center: a prospective observational study.

Dadlez NM, Azzarone G, Sinnett MJ, et al. Hosp Pediatr. 2017;7:134-139.

Interruptions are known to contribute to medication errors. This direct observation study found that resident physicians and physician assistants experienced 57 interruptions per 100 medication orders. The authors suggest that inpatient health systems should implement strategies to reduce interruptions during medication ordering.

Cases & Commentaries

The Hazards of Distraction: Ticking All the EHR Boxes

  • Spotlight Case
  • CME/CEU
  • Web M&M

Anthony C. Easty, PhD; February 2017

A few weeks after falling and hitting her head, a woman with metastatic cancer was admitted to the hospital for observation after a brain scan showed a subdural hematoma with a midline shift. Repeat imaging showed an enlarging hematoma, which required surgical evacuation. The admitting provider had mistakenly prescribed blood thinner for venous thromboembolism prophylaxis (contraindicated in the setting of subdural hematoma) by clicking the box in the electronic health record admission order set.

Journal Article > Study

Data-driven implementation of alarm reduction interventions in a cardiovascular surgical ICU.

Allan SH, Doyle PA, Sapirstein A, Cvach M. Jt Comm J Qual Patient Saf. 2017;43:62-70.

Reducing the number of alarms can help alleviate alarm fatigue and the associated patient safety hazards. In this study, researchers successfully implemented a number of interventions which led to a 61% decrease in average alarms per monitored bed in a cardiovascular surgical intensive care unit and a reduction in cardiorespiratory events.

Journal Article > Study

Separate medication preparation rooms reduce interruptions and medication errors in the hospital setting: a prospective observational study.

Huckels-Baumgart S, Baumgart A, Buschmann U, Schüpfer G, Manser T. J Patient Saf. 2016 Dec 21; [Epub ahead of print].

Interruptions are known to contribute to medication administration errors. This pre–post study found that nurses experienced fewer interruptions and made fewer medication errors following the introduction of a separate medication room. These results demonstrate how changing the work environment can promote safety.

Journal Article > Commentary

Implementing No Interruption Zones in the perioperative environment.

Wright MI. AORN J. 2016;104:536-540.

Noise in the operating room can contribute to miscommunication, stress, and fatigue. This commentary describes a project that established a designated quiet space in an outpatient surgical setting to decrease opportunities for distraction in perioperative care and provided education regarding the importance of noise reduction.

Journal Article > Review

Disruptive behaviour in the perioperative setting: a contemporary review.

Villafranca A, Hamlin C, Enns S, Jacobsohn E. Can J Anaesth. 2017;64:128-140.

Disruptive clinician behavior has a negative effect on teamwork that could contribute to patient harm. Examining the literature on disruptive behavior in the operating room, this review identified intrapersonal, organizational, and interpersonal factors that facilitate disruptive conduct and discussed its impact on teams, clinicians, patients, and organizations. The authors recommend strategies to address disruptive behaviors among clinicians such as documenting standards of behavior.

Journal Article > Review

Traditions of research into interruptions in healthcare: a conceptual review.

McCurdie T, Sanderson P, Aitken LM. Int J Nurs Stud. 2017;66:23-36.

Interruptions are prevalent in health care delivery settings. This review discusses epidemiology, quality improvement, cognitive systems engineering, and applied cognitive psychology as prominent research traditions examining interruptions in health care. The authors suggest that a more integrated approach that combines perspectives from these research traditions could enhance design of interventions to reduce interruptions.

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