Understanding the Types and Effects of Clinical Interruptions and Distractions Recorded in a Multihospital Patient Safety Reporting System.
Citation: Journal of patient safety. 17(8):e1394-e1400, 2021 12 01.PMID: 29994817Institution: MedStar Institute for InnovationDepartment: National Center for Human Factors in HealthcareForm of publication: Journal ArticleMedline article type(s): Journal ArticleSubject headings: *Patient Safety | *Pharmaceutical Preparations | Humans | Medication Errors | Retrospective Studies | WorkloadYear: 2021Local holdings: Available online through MWHC library: March 2005 - presentISSN:- 1549-8417
Item type | Current library | Collection | Call number | Status | Date due | Barcode |
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Journal Article | MedStar Authors Catalog | Article | 29994817 | Available | 29994817 |
Available online through MWHC library: March 2005 - present
CONCLUSIONS: This retrospective review of PSE reports involving interruptions of clinical activities reveals that interruptions affect a variety of aspects of patient care and can help to guide future work on interruption management. Copyright (c) 2018 Wolters Kluwer Health, Inc. All rights reserved.
METHODS: We retrospectively analyzed PSE reports entered by frontline staff between January 2013 and January 2016. Of 79,428 total PSEs entered, 220 reports were identified using keyword matching and subsequent manual review as being directly related to a clinical interruption. Categories were developed to identify the cause of the interruption, task being interrupted, and the result of the interruption. Percentages were calculated.
OBJECTIVES: Interruptions and distractions have been shown to be a frequent occurrence across health care and have been linked to negative outcomes that create potential patient safety risks. Although observational studies have catalogued interruption frequency and source, the impact of an interruption is difficult to observe. We analyzed patient safety event (PSE) reports related to interruptions to identify clinical processes reported to be frequently interrupted and the reported outcomes of those interruptions.
RESULTS: Nurses were most often reported to be interrupted in the PSEs (50%). General distractions (43.2%) or high workload (18.6%) were most commonly noted to interrupt the individual's work. The interrupted activity was most often a medication task (50.9%), frequently in the administration phase (24.1%), or the ordering phase (16.8%). The most common medication error was wrong dose administration (14.4% of total medication-related errors). Laboratory processes were reported to be disturbed by interruptions in 22.7% of reports, and this frequently resulted in mislabeling of specimens (75% of laboratory-related errors).
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