Search results for "Interruptions and distractions"

Admitted to the intensive care unit (ICU) with acute respiratory distress syndrome due to severe pancreatitis, an older woman had a central line placed. Despite maximal treatment, the patient experienced a cardiac arrest and was resuscitated. The intensivist was also actively managing numerous other ICU patients and lacked time to consider why the patient's condition had worsened.

Chemotherapy medications can cause severe patient harm if incorrectly dosed or administered. This cross-sectional survey of oncology nurses revealed that most chemotherapy double-checking is conducted jointly rather than independently. Of note, many nurses reported being interrupted to engage in a double-check.

Despite the ubiquity of smartphones, the vast majority of physicians still rely on one-way pagers for communication. This study analyzed the frequency and content of pages on an internal medicine service at a teaching hospital and compared the data to a similar study performed in 1988. Physicians received an average of 22 pages per day, of which 76% were deemed clinically relevant by independent reviewers and 82% required a response. This represented a nearly 50% increase in the volume of pages compared to 1988. Doctors on regionalized services (where patients were admitted to a common unit) received significantly fewer pages than those caring for patients on nonregionalized services, implying that regionalized services may aid face-to-face communication. As interruptions have been shown to negatively affect patient safety, the authors advocate for developing secure two-way methods of communication (such as secure text messaging) for nurses and physicians in order to improve the efficiency of communication around clinical issues.

Pagers have been a mainstay for urgent clinician–clinician communication for many decades. Increasingly physicians are using a variety of electronic devices, including smartphones and Web-based technologies. This systematic review identified 16 articles that studied different technologies for urgent clinician communication. Each strategy had potential advantages and pitfalls. For example, smartphones are associated with decreased transmission time compared to pagers, but they also result in more clinician interruptions. There is very little evidence linking any specific communication method with benefits for patient care. Future study could more robustly explore which forms of communication are best for clinicians and patients. A prior AHRQ WebM&M commentary describes a case of serious patient harm related to a smartphone interruption.

According to this study, information regarding the plan of care was generally accurately transmitted during resident handoffs in the emergency department. However, medications were often omitted and residents were frequently interrupted.

This direct observation study found that registered nurses, physicians, and nursing aides have frequent interruptions and limited time for shift-change handoffs. This finding suggests that widespread efforts to ensure adequate handoff time and minimize interruptions have not mitigated these problems in hospital settings.

Safe patient care requires effective communication between health care providers. Hospitals currently use various communication strategies including alphanumeric pagers, smartphones, and Web-based communication tools. The utility and effectiveness of many such systems have not been tested. This ethnographic study of five teaching hospitals discusses the potential benefits and unintended effects of different communication systems. For instance, smartphones made it easier to respond to requests, but seemed to increase interruptions. An AHRQ WebM&M commentary illustrates a serious adverse event resulting from a smartphone interruption.

This commentary describes a four-step process to help frontline caregivers identify and address safety concerns, such as interruptions in daily work.

Interruptions were associated with an increased risk of miscommunication between team personnel during surgical procedures. Teams that had limited experience working together seemed to be particularly vulnerable to miscommunications.

The majority of individual errors are due to failure to perform automatic or reflexive actions. A major risk factor for these "slips" is being interrupted or distracted while performing a task. This review examined the literature on the incidence, risk factors, and effects of interruptions in several clinical settings, ranging from outpatient clinics to the operating room. Although distractions are common and may be associated with increased risk for error, particularly if they occur during medication administration or signout, the authors point out that many interruptions may be necessary to communicate urgent clinical information. They argue for complexity theory–based research to delineate the harmful and beneficial aspects of interruptions, rather than for interventions that seek to simply eliminate interruptions. Checklists have been widely adopted as a means of preventing errors of omission, which may be precipitated by interruptions.

This article discusses one hospital's effort to understand how interruptions affect care and to improve processes based on experience from other industries.

This study observed emergency room charge nurses and discovered that interruptions and unnecessary information exchange increased their communication load and the potential for errors.

This study used link analysis techniques in observing that face-to-face communication was the most common mode among different provider types in an emergency department. The charge nurse was observed to be the center of communication while interruptions were a common event for both physicians and nurses.

The investigators shadowed emergency department nurses and physicians and identified the types of interruptions that occurred and what factors contributed to them.

The researchers observed a urology surgery team to measure the frequency and source of interruptions in the operating theater.

This study evaluated factors that jeopardize safe decision-making using ethnographic observation and interviews. Using a high-paced emergency department (ED) setting, investigators discovered that interruptions occurred nearly every 10 minutes for attending physicians. Observed gaps in communication resulted from poor information flow complicated by inherent multitasking, shift changes, and other activities such as documentation time and utilization of computer resources. The authors present typical workflow patterns in the ED and provide a summary of interview responses to illustrate the taxing nature of cognitive overload facing the studied clinicians. They conclude that carefully designed technology can minimize the effect that interruptions and handoffs have on patient safety.

A nurse notices that an IV medication she is about to administer is possibly mislabeled, as it looks like a different drug. However, she is interrupted before she can call the pharmacy and winds up hanging the bag anyway.

Handoffs present a significant patient safety hazard across multiple health care settings. Interruptions and distractions, which can interfere with handoff communication, are prevalent in pharmacy environments. This cross-sectional survey of community pharmacies found that virtually none of the pharmacists had received training in how to hand off information. A significant proportion of responses indicated that pharmacy information technology systems do not support handoff communication. Respondents reported that handoffs are frequently inadequate or inaccurate. The authors conclude that interventions are needed to enhance the quality of handoff communication in community pharmacy settings to prevent dispensing errors.

This quarterly commentary explores a wide range of subjects associated with patient safety, such as the impact of disruptive behavior on teams, the value of apologies, and work hour reforms. Older materials are available online for free.

Discontinuity is an unfortunate but necessary reality of hospital care. No provider can stay in the hospital around the clock, creating the potential for errors when clinical information is transmitted incompletely or incorrectly between clinicians.