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Showing results for tags 'Distractions/ interruptions'.
Found 29 results
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Content ArticleThis study in the Annals of Surgery aimed to characterise errors, events and distractions in the operating theatre, and measure the technical skills of surgeons in minimally invasive surgery practice. The authors of the study implemented the use of an operating room (OR) Black Box, a multiport data capture system that identifies intraoperative errors, events and distractions. The study found that the OR Black Box identified frequent intraoperative errors and events, variation in surgeons’ technical skills and a high number of environmental distractions during elective laparoscopic operations.
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Research shows that poor handover in hospitals puts patients at risk of severe harm
Anonymous posted an article in Handover
Research undertaken by digital health platform, CAREFUL shows that handover in hospitals is the cause of frequent and severe harm to patients. -
Content ArticleIn this blog, a patient who experienced life-changing surgical complications describes the process of reconciliation between medical staff and patients when harm has occurred in healthcare. She highlights the need for both the patient and healthcare professional to be engaged and open in the process. She also looks at how different human factors can negatively impact on the duty of candour process, and why they need to be acknowledged. These factors include lack of communication, distraction, lack of resources, stress, complacency, lack of teamwork, pressure, lack of awareness, lack of knowledge, fatigue, lack of assertiveness and norms.
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Content ArticleIn this clinical case report for the Association of Anaesthetists, the authors reflect on the importance of error reporting and implementing learning from clinical mistakes. They look at several error-related incidents and examine key learning points. They highlight that cases that do not result in serious harm to the patient are not prioritised for entry into databases or national audits, meaning they are less likely to be the subject of system-based improvement projects when compared with more ‘serious’ events. They identify that this may cause gaps in clinicians' awareness of potential risks and error traps. The authors also examine the impact that learning projects based on incident reporting can have on clinicians involved in the initial incidents, highlighting that revisiting errors may prevent individuals from moving on from them.
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Content ArticleThis study in The British Journal of General Practice aimed to quantify the time GPs spend on different activities during clinical sessions, to identify the number of operational failures they encounter and to define the nature of operational failures and their impact for GPs.
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Content ArticleThe aim of this study from Mahadevan et al. was to understand human factors (HF) contributing to disturbances during invasive cardiac procedures, including frequency and nature of distractions, and assessment of operator workload. They observed 194 cardiac procedures in three adult cardiac catheterisation laboratories over 6 weeks. The study found that fewer than half of all procedures were completed without interruption/distraction. The majority were unnecessary and without relation to the case or list. The authors propose the introduction of a ‘sterile cockpit’ environment within catheter laboratories, as adapted from aviation and used in surgical operating theatres, to minimise non-emergent interruptions and disturbances, to improve operator conditions and overall patient safety.
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Content ArticleThis list, produced by the Health and Safety Executive, bullet points the job, person and organisation factors that influence human performance.
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Content ArticleInterruptions and multitasking are implicated as a major cause of clinical inefficiency and error. The aim of this study by Westbrook et al. was to measure the association between emergency doctors' rates of interruption and task completion times and rates.
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Content ArticleOrganisations expect to see consistency in the decisions of their employees, but humans are unreliable. Judgments can vary a great deal from one individual to the next, even when people are in the same role and supposedly following the same guidelines. And irrelevant factors, such as mood and the weather, can change one person’s decisions from occasion to occasion. This chance variability of decisions is called noise, and it is surprisingly costly to companies, which are usually completely unaware of it.
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Content ArticleAn educational session from The Association for Perioperative Practice (AfPP) dedicated to the dangers of noise and distraction in healthcare with a possible solution, Below Ten Thousand. Below Ten Thousand is a language-based safety tool for any clinical arena where 'noise and distraction' is a problem, and where high performance teams need to quickly gain 'situational awareness' and ‘directed focus’ in order to successfully navigate the perils of acute healthcare whilst providing first class interventions.
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Content ArticleIn everyday life and in health care environments, distractions and interruptions are threats to human performance and safety. A distraction may occur when a driver is texting while in traffic or when a health care professional is interrupted during a high-risk task such as prescribing or administering a medication. Interruptions—ringing telephones, active alarms or computerized alerts, or even being asked a question – are ubiquitous in society, and health care is no exception. This article by nurse, Suzanne Beyea, discusses how mindfulness can reduced distraction and improve patient safety. Published by the Patient Safety Safety Network.
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Content ArticleClinical decisions rarely occur in isolation. We must consider the social contexts in clinical environments and draw on theories of social emotion to help us better understand the influence of others’ emotion on our own thoughts, feelings and, ultimately, our ability to deliver safe care. In their Editorial in BMJ Quality & Safety, Jane Heyhoe and Rebecca Lawton explorie the role of social emotion in patient safety and looks at the recent research in this emerging area. They call on the patient safety community to embrace the idea that emotions and emotional contexts exert important impacts on healthcare delivery. Characterising these impacts will inform strategies for supporting staff and delivering safer and more effective care to patients.
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Content ArticleThe human factors ‘Dirty Dozen’ is a concept developed by Gordon DuPont. He described elements that can act as precursors to accidents or incidents, or influence people to make mistakes. This article by the Clinical Excellence Commission introduces the 'dirty dozen' and offers practical tips on how to reduced error int he workplace.
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Content ArticleMore than six weeks into the lockdown and if you were to gauge the mood of the nation, it would be one of fatigue. It started as an all-hands-on-deck emergency situation, but it now transpires that the current work situation for healthcare professionals is not going to change any time soon. This is a marathon rather than a sprint. So how can we better look after ourselves to cope with this new realisation? This BMJ podcast features Dr Caroline Walker, an NHS-based psychiatrist and therapist. Wait until the end for Caroline's simple technique she uses to help when feeling overwhelmed.
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Safe handover of a critically unwell patient to intensive care
Claire Cox posted an article in Techniques
Handing over a patient to a team in critical care needs to be clear, concise and safe. Quite often there are distractions from staff moving the patient, attaching monitoring, starting the ventilator, asking questions and general background noise. This can lead to important information being missed, not understood or misinterpreted which could lead to patient harm. -
Content Article
Why I ‘walk on by’
Anonymous posted an article in Florence in the Machine
I recently read the blog on the hub ‘Walk on by...’ by a junior doctor. What a fantastic doctor, if only we had more of these people in our healthcare service. I wanted to respond to this blog by writing about my own experiences in ‘walking on by’. It’s been a difficult write as it has questioned my integrity, my motivation and my career.- Posted
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Content ArticleIn 1991, the Institute of Medicine released a landmark report revealing that as many as 98,000 patients a year were dying due to avoidable medical error. But even more recent research indicates that estimate was, if anything, a drastic understatement of the patient-safety crisis in the US healthcare system. In Malpractice, neurosurgeon and attorney Dr. Larry Schlachter demonstrates how most patients enter the system without any idea of the risks they face due to a medical culture that avoids transparency, perpetuates an atmosphere of blind deference to doctors, and protects dangerous doctors from any accountability. Drawing on twenty-three years of experience, Dr. Schlachter recounts unbelievable stories that illustrate the host of risks patients face whenever they seek diagnostic evaluation or go under the knife. This book brings readers inside the healthcare citadel, exposing the flawed culture that can fuel egos and outlining the steps every patent should take to protect himself or herself in “a bitter pill for an industry that for many years has avoided the hardest conversations about patient safety.”—Dr. Michael Dogali, MDCM, FACS, president of Pacific Neurosurgery
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Content ArticleFatigue is a complex phenomenon that has effects on physical characteristics, cognition, behaviours, and physical and mental health. Paramedicine crosses the boundaries of many high-risk industries, namely medicine, transport and aviation. The effects of fatigue on paramedics need to be explored and considered in order to begin to identify appropriate interventions and management strategies. This article, published in the Irish Journal of Paramedicine, demonstrates that fatigue is associated with increased errors and adverse events, increased chronic disease and injury rates, depression and anxiety, and impaired driving ability. It has suggested that paramedic services and paramedics need to work collaboratively to identify and action appropriate measures to reduce the effects of fatigue on the wellbeing of the workforce and mitigate its effects on clinical performance and safety.
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RCOG: Video briefing on human factors and situational awareness
Claire Cox posted an article in Maternity
Each baby counts is the Royal College of Obstetricians and Gynaecologist's national quality improvement programme to reduce the number of babies who die or are left severely disabled as a result of incidents occurring during term labour. Watch the Each baby counts human factors video for information on how to address issues within your unit. -
Content ArticleBen Tipney and Vikki Howarths' presetation on Human Factors in practice. This presentation covers: an introduction to human factors human factors training implementation of human factors in practice new initiatives.
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10 quality indicators for clinical consultation (2016)
Dr Gordon Caldwell posted an article in Clinical leadership
The process of clinical consultation defines diagnosis and is crucial to patient safety and patient outcomes However the process is frequently weak resulting in care erring off path. These indicators (taken from a paper in Postgraduate Medical Journal) could provide a way to identify weaknesses and areas for improvement.- Posted
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Content ArticleHindSight is a magazine produced by the Safety Improvement Sub-Group (SISG) of EUROCONTROL. It is produced for Air Traffic Controllers and is issued by the Agency twice a year. Its main function is to help operational air traffic controllers to share in the experiences of other controllers who have been involved in ATM-related safety occurrences. The current Editor in Chief is Dr Steven Shorrock.
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Content ArticleReacting to a never event is difficult and often embarrassing for staff involved. East Lancashire Hospitals NHS Trust has demonstrated that treating staff with respect after a never event, creates an open culture that encourages problem solving and service improvement. The approach has allowed learning to be shared and paved the way for the trust to be the first in the UK to launch the patient centric behavioural noise reduction strategy ‘Below ten thousand’. Published in the Journal of Perioperative Practice.
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Content ArticleThis edited book concerns the real practice of human factors and ergonomics (HF/E), conveying the perspectives and experiences of practitioners and other stakeholders in a variety of industrial sectors, organisational settings and working contexts.
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Content ArticleResearchers have shown that people often miss the occurrence of an unexpected yet salient event if they are engaged in a different task, a phenomenon known as inattentional blindness. However, demonstrations of inattentional blindness have typically involved naive observers engaged in an unfamiliar task. What about expert searchers who have spent years honing their ability to detect small abnormalities in specific types of images? We asked 24 radiologists to perform a familiar lung-nodule detection task. A gorilla, 48 times the size of the average nodule, was inserted in the last case that was presented. Eighty-three percent of the radiologists did not see the gorilla. Eye tracking revealed that the majority of those who missed the gorilla looked directly at its location. Thus, even expert searchers, operating in their domain of expertise, are vulnerable to inattentional blindness.
