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Search results for "Interruptions and distractions"

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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.

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 > 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

Medication errors in hospitals: a literature review of disruptions to nursing practice during medication administration.

Hayes C, Jackson D, Davidson PM, Power T. J Clin Nurs. 2015;24:3063-3076.

This systematic review found clear consensus that disruptions worsen the safety of medication administration by nursing, and interventions to reduce such interruptions can improve safety. Investigators identified effective management of unavoidable interruptions as a gap in current research and training for nurses.

Special or Theme Issue

Quality and Safety.

Albarran J, Scholes J, eds. Nurs Crit Care. 2015;20:167-220.

Nurses have a key role in patient safety and advocacy in critical care settings. Articles in this special issue explore the impact of interruptions on nursing care, ward rounds as an opportunity for checklist use, and the importance of integrating safety concepts into nursing education.

Journal Article > Study

Disrupting diagnostic reasoning: do interruptions, instructions, and experience affect the diagnostic accuracy and response time of residents and emergency physicians?

Monteiro SD, Sherbino JD, Ilgen JS, et al. Acad Med. 2015;90:511–517.

This study used written medical cases to examine whether simulated time pressure or interruptions affect diagnostic accuracy among resident and attending emergency medicine physicians. While the experienced physicians answered the questions more quickly and accurately compared to resident physicians, diagnostic accuracy was not compromised by time pressure or interruptions for either group in this study.

Journal Article > Study

Driven to distraction: a prospective controlled study of a simulated ward round experience to improve patient safety teaching for medical students.

Thomas I, Nicol L, Regan L, et al. BMJ Qual Saf. 2015;24:154-161.

Interruptions are common in the clinical environment and pose a significant safety hazard for health care providers performing complex tasks. This educational intervention used a simulation of ward rounds for final year medical students. Investigators examined rates of errors following interruptions or distractions. One group received targeted feedback on managing distractions while the control students received no feedback. Although simulation reduced the number of errors following interruptions and distractions, feedback conferred an additional decrease in errors as well. This work demonstrates that medical students are not adequately trained to manage common distractions and interruptions. Simulation with targeted feedback is an effective strategy for medical students to safely manage distractions and interruptions. A past AHRQ WebM&M commentary reflects on the relationship between interruptions and errors.

Journal Article > Commentary

Creating a distraction simulation for safe medication administration.

Thomas CM, McIntosh CE, Allen R. Clin Simul Nurs. 2014;10:406-411.

Nursing students and new registered nurses are more likely to make mistakes during medication administration due to lack of experience and insufficient knowledge. This commentary describes the development and implementation of a simulation program to help students experience the various interruptions and distractions that occur in the hospital environment while preparing medications to understand how they can contribute to errors and learn about risks associated with multitasking.

Journal Article > Study

The perceptions of nurses towards barriers to the safe administration of medicines in mental health settings.

Hemingway S, McCann T, Baxter H, Smith G, Burgess-Dawson R, Dewhirst K. Int J Nurs Pract. 2015;21:733-740.

Medication errors are common in mental health care. This survey of nurses and nursing students identified interruptions and insufficient medication knowledge as major barriers to ensuring medication safety in outpatient mental health.

Journal Article > Study

Realistic distractions and interruptions that impair simulated surgical performance by novice surgeons.

Feuerbacher RL, Funk KH, Spight DH, Diggs BS, Hunter JG. Arch Surg. 2012;147:1026-1030.

In this study involving surgical residents, the introduction of realistic interruptions and distractions into simulated surgical scenarios resulted in a significantly higher incidence of technical errors during the procedures.

Special or Theme Issue

Cognitive Factors in Health Care.

Rogers WA, ed. J Exp Psychol Appl. 2011;17:191-302.

Articles in this special issue explore the impact of cognition on health care activities such as patient identification, interruptions, and team communication.

Journal Article > Study

Interruptions and blood transfusion checks: lessons from the simulated operating room.

Liu D, Grundgeiger T, Sanderson PM, Jenkins SA, Leane TA. Anesth Analg. 2009;108:219-222.

This simulation study examined the effect of distractions on anesthesiologists' performance of measures to ensure blood transfusion safety.

Cases & Commentaries

Workaround Error

  • Web M&M

Tess Pape, PhD, RN, CNOR; February 2006

Bypassing the safeguards of an automated dispensing machine in a skilled nursing facility, a nurse administers medications from a portable medication cart. A non-diabetic patient receives insulin by mistake, which requires his admission to intensive care and delays his chemotherapy for cancer.

Cases & Commentaries

Deciphering the Code

  • Web M&M

Mary K. Goldstein, MD, MS ; February 2006

Failure to enter documentation of a DNR order causes a severely ill elderly man to be resuscitated against his wishes. Shortly thereafter, the patient's wife confirms his wishes, and within minutes, the patient dies.

Cases & Commentaries

Missed Appendicitis

  • Spotlight Case
  • Web M&M

James G. Adams, MD; June 2003

Abdominal pain misdiagnosed in an ED patient leads to ruptured appendix, multiple complications, and prolonged hospitalization.

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