Search results for "United States of America"

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.

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.

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.

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.

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.

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.

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.

Personal electronic devices such as smartphones are now ubiquitous, and many clinicians use them for both work and personal purposes. Although considered a necessity, these devices can serve as a distraction, which could compromise patient safety. This review found that many certified registered nurse anesthetists and anesthesiologists acknowledge using personal electronic devices in the operating room despite knowledge of the potential risks. Currently, no formal guidelines exist regarding what constitutes inappropriate use of such devices in the operating room. The authors call for further research in order to develop policies to balance the risks and benefits of personal electronic devices. A WebM&M commentary discusses a case where an interruption due to receiving a text message on a smartphone led to a serious medication error.

Medication administration errors are common and are often associated with interruptions. This study reviews data from a recent study on medication safety in critical access hospitals and recommends organizational strategies to improve the safety of medication administration.

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.

Interruptions can lead to errors in care, but they may be necessary to address urgent situations. This direct observation and device audit study classified nursing interruptions as either detrimental or necessary. Investigators determined that interrupting a nurse in the patient room was most likely to be a safety hazard, whereas alerts to nurses outside of patient rooms were more likely to be beneficial. This work underscores the challenge of optimizing interruptions to maintain patient safety.

Interruptions and task-switching are common contributors to complexity in emergency care. Exploring behaviors associated with multitasking in various disciplines, including human factors engineering, cognition science, and business, this review outlines a framework for enhancing understanding of multitasking, such as whether it can be performed successfully and types of actions that can be combined safely.

Interruptions are a known safety hazard that occur frequently. This systematic review proposes that interruptions be considered a process with various potential consequences for multiple actors rather than single events and suggests a human factors approach to addressing interruptions.

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.

Ineffective implementation of health information technology (IT) can result in workarounds and other workflow changes that disrupt care delivery. This report examines how health IT implementation can affect clinician and staff workload in the ambulatory care environment, including increase interruptions and multitasking, and recommends workload considerations to enable staff to adapt to changes in practice.

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.

Errors in surgical care are often associated with human factors, interruptions, and staffing issues. This commentary describes a program to augment safety in ambulatory surgery centers, which includes a surgical checklist, change management, and teamwork.

High-alert medications have the potential to cause serious patient harm. This article focuses on four primary types of high-alert medications—anticoagulants, sedatives, insulins, and opioids—that can have serious adverse effects and recommends strategies to reduce risks, including conducting independent double-checks and decreasing interruptions.

Implementation of a safe zone—which included marked quiet areas for medication preparation, adhering to a checklist for medication processes, and educating staff about distractions—to minimize interruptions during medication administration did not improve medication error rates, but was associated with an increase in patient satisfaction.

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.