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Search results for "Interruptions and distractions"

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Journal Article > Study

Shift change handovers and subsequent interruptions: potential impacts on quality of care.

Estryn-Behar MR, Milanini-Magny G, Chaumon E, et al. J Patient Saf. 2014;10:29-44.

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.

Journal Article > Study

Quality of handoffs in community pharmacies.

Abebe E, Stone JA, Lester CA, Chui MA. J Patient Saf. 2017 Apr 27; [Epub ahead of print].

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.

Patient Safety Primers

Handoffs and Signouts

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.

Cases & Commentaries

All in the History

  • Spotlight Case
  • Web M&M

Christopher Fee, MD; February-March 2009

Interrupted during a telephone handoff, an ED physician, despite limited information, must treat a patient in respiratory arrest. The patient is stabilized and transferred to the ICU with a presumed diagnosis of aspiration pneumonia and septic shock. Later, ICU physicians obtain further history that leads to the correct diagnosis: pulmonary embolism.

Cases & Commentaries

Triple Handoff

  • Spotlight Case
  • Web M&M

Arpana R. Vidyarthi, MD; September 2006

An elderly man was admitted to the hospital for pacemaker placement. Although the postoperative chest film was normal, the patient later developed shortness of breath. Over the course of several nursing and physician shift changes and signouts, results of a follow-up stat x-ray are not properly obtained, delaying discovery of the patient's pneumothorax.

Cases & Commentaries

Fumbled Handoff

  • Web M&M

Arpana Vidyarthi, MD; March 2004

Due to a series of incomplete signouts, information about a patient's post-operative leg pain and chest discomfort is not conveyed to the primary team. A PE is discovered post-mortem.

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