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Showing results for tags 'Distractions/ interruptions'.
Found 28 results
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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 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 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 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 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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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. Walking by is not what I want to do but walking by is what I do on a regular basis. I am ashamed to write this, to think this, to do this. I don’t think I am alone as I have seen others do it too. We are not bad people, but I can’t help but think that we have turned into bad nurses. The last thing I wanted to be was a bad nurse. This was never the plan… it’s crept in, without me knowing it was happening. Until now. How has this happened? How have I become the nurse I despise? I work on an acute medical admissions unit. We have patients that are admitted from the emergency department (ED). They are unwell, often too unwell to come to us, but patients need to be moved. “Keep ED flowing” – its all about flow. I have begun to hate that word. We have 36 beds in total. We have a nurse/patient ratio of 1:6. Sometimes 1:8 if we are short staffed. Throughout the day we can have up to 12 patients that have passed through those six beds. They go to other medical wards, respiratory wards… anywhere that has space. If we have no room the ED gets backed up and ‘flow’ stops. I have pressure from my nurse in charge to move my patient to another ward, they have pressure from the bed manager, who has pressure from the ops manager. I have sat in on bed meetings, it’s not easy listening. A high up manager barking “we need 45 discharges by mid-day”; it’s not achievable… it goes on every day. I’m getting these patients ready for transfer. Safety booklets, pages long to be completed: nutritional score, waterlow score, bowel chart, touch the toes chart, fluid chart, turns chart, fall proforma, NEWS charting, food chart, clinical pathways, next of kin contact details, let alone my documentation for those few hours they have sat in that bed. All the while, drugs need to be given, intravenous drugs, not just for my patient but I have to help the agency nurse in the next bay as “she can’t do IVs”. Patients need washing, turning, feeding, monitoring, bloods to be taken, wounds to be dressed, hourly pump checks, blood sugar testing, cannulation and conversations with sick patients’ relatives. These are tasks that need to be done on time. If not – trust policy is breached. Some, I just ‘tick’, especially if it’s a checklist. I know I’m not the only one that does this – it’s normal. So, when I’m in the middle of trying to complete these ever-growing tasks, I hear “nurse can you…” “nurse will you just…” “I know you're busy but...” What do I do? I walk on by. I walk at high speed. I have stopped before. It often stops me completing my tasks. I forget what I was meant to be doing. I have missed a crucial blood sugar check for my DKA patient in the past. Patients do not get their medication on time, patients are not transferred on time (it’s all about the flow), safety booklets not completed, handovers rushed and information missed, documentation scant. I’m always in a rush. I know many of the calls are for toileting. This can take a while. I daren’t look at the pressure areas – my heart sinks if there is one… more documentation, more time away from the other tasks. Patients who come in are often at risk of falling, so need two people to help. I know the next-door nurse is just as busy; I feel bad to ask her/him. The healthcare assistant is often too busy to help, getting patients ready for transfer, doing the observations… relentless. Walk on by. Yes, I do. I am not the only one. What are the Trust priorities? Safe care or flow? The Trust will always say safe care. So why set up the environment that causes unsafe care? Mixed messages. I became a nurse to give evidence-based, holistic, safe care. I go home demoralised. I don’t recognise this profession anymore.- Posted
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Content Article
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. Key themes: Situational awareness Handover resources Interruptions and distractions Delegation Task-fixation, helicopter view & closed-loop communication Ask for help. -
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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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. This issue of Hindsight includes articles on: Malicious compliance by Sidney Dekker Can we ever imagine how work is done? by Erik Hollnagel Safety is in the eye of the beholder by Florence-Marie Jegoux, Ludovic Mieusset and Sébastien Follet I wouldn't have done what they did by Martin Bromiley
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Content Article
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 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.
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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. The book blends literature on the nature of practice with diverse and eclectic reflections from experience in a range of contexts, from healthcare to agriculture. It explores what helps and what hinders the achievement of the core goals of human factors and ergonomics (HF/E): improved system performance and human wellbeing. The book should be of interest to current HF/E practitioners, future HF/E practitioners, allied practitioners, HF/E advocates and ambassadors, researchers, policy makers and regulators, and clients of HF/E services and products.
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Content Article
Below Ten Thousand video
Patient Safety Learning posted an article in Processes
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. The operating theatre works daily by the premise of ‘surgical precision’. Every opportunity to work as a holistic team is embraced, not only as an effective way to get things done, but also as a way to maximise patient safety and reduce risk. Given the intensity of the work and the mandatory desire for a good outcome, surgeons, anaesthetists, nurses and theatre technicians are embracing a new concept in operating theatre team dynamics. The concept has been developed by nurses at Geelong Hospital. John Gibbs, a Clinical Nurse Specialist in Anaesthetics, studied Crew Resource Management strategies common in the airline industry and found that some dimensions of aeronautical crew resource engineering could solve dilemmas in his operating theatre environment, in particular, the reduction of ambient noise and distractions at sentinel times of anaesthesia. In collaboration with other staff, he has worked on and improved upon the idea, finally arriving at the prototype concept of ‘Below Ten Thousand’ for the surgical and clinical setting. -
Content Article
Human error: models and management
Claire Cox posted an article in Improving patient safety
In this BMJ article, James Reason discusses how the human error problem can be viewed in two ways: the person approach and the system approach. Each has its model of error causation and each model gives rise to quite different philosophies of error management. Understanding these differences has important practical implications for coping with the ever present risk of mishaps in clinical practice. Key learning points Two approaches to the problem of human fallibility exist: the person and the system approaches. The person approach focuses on the errors of individuals, blaming them for forgetfulness, inattention, or moral weakness. The system approach concentrates on the conditions under which individuals work and tries to build defences to avert errors or mitigate their effects. High reliability organisations—which have less than their fair share of accidents—recognise that human variability is a force to harness in averting errors, but they work hard to focus that variability and are constantly preoccupied with the possibility of failure. -
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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Content Article
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. This short video shows how Brighton and Sussex University Hospitals NHS Trust has transformed the way that handover is received. By using a simple checklist along with a process, the critically unwell patient can be handed over quickly and safely. Further reading attached: Standard Operating Procedure for ICU/HDU Handover South East Coast Critical Care Network Critical Care Intrahospital Transfer form -
Content ArticleIn many safety-critical environments, including healthcare, operators need to remember to perform a deferred task, which requires prospective memory. Laboratory experiments suggest that extended prospective memory retention intervals, and interruptions in those retention intervals, could impair prospective memory performance. The aim of this study, published in Human Factors journal, was to examine the effects of interruptions and retention interval on prospective memory for deferred tasks in simulated air traffic control. This can be translated into a healthcare environment.
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Content ArticlePotentially preventable adverse events remain a formidable cause of patient harm and health care expenditure despite advances in systems-based risk-reduction strategies. This quality improvement study from Suliburk et al., published in JAMA Network Open, analysed the incidence of human performance deficiencies during the provision of surgical care to identify opportunities to enhance patient safety. From the 5365 operations, 188 adverse events were recorded. Of these, 106 adverse events (56.4%) were due to human error, of which cognitive error accounted for 99 of 192 human performance deficiencies (51.6%). These data provide a framework and impetus for new quality improvement initiatives incorporating cognitive training to mitigate human error in surgery.
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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. The authors conducted a prospective observational time and motion study in the emergency department of a 400-bed teaching hospital. They found that doctors were interrupted 6.6 times/h. 11% of all tasks were interrupted, 3.3% more than once. Doctors multitasked for 12.8% of time. It appears that in busy interrupt-driven clinical environments, clinicians reduce the time they spend on clinical tasks if they experience interruptions, and may delay or fail to return to a significant portion of interrupted tasks. Task shortening may occur because interrupted tasks are truncated to ‘catch up’ for lost time, which may have significant implications for patient safety.
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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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Content Article
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. Handover in hospitals is the cause of frequent and severe harm to patients, according to new research* by digital health platform, CAREFUL. Many patients are suffering because handover is poorly controlled and under-recognised as a source of clinical risk. Handover is the transfer of responsibility and crucial patient information between practitioners and teams. Handover takes place when shifts change and when patients are transferred between departments or outside of the hospital into another care setting. This is a time when staff are under pressure and when mistakes can happen – as the research shows. “We undertook this research because little is known about how practitioners see the risks of handover and the impact of handover on patient safety,” says CAREFUL CEO, Dr DJ Hamblin-Brown. “We anticipated that doctors and nurses would report some errors, but the frequency with which harm is reported across the world is disturbing.” Patient safety in operating theatres has been a recognised problem for many years – ever since the publication of the original checklist article in the New England Journal of Medicine. By contrast, handover, despite being possibly the most common clinical process across healthcare, has not been studied so widely. CAREFUL’s research investigated clinicians’ experience of handover, receiving 432 completed responses from clinicians in 26 countries via an open, anonymous and confidential online questionnaire. Published in February 2022, the findings revealed that errors in handover occur weekly or daily, according to 12% of respondents. Nearly 10% had witnessed severe harm – either death or otherwise life changing – because of handover error. “Handover takes place about 4,000 times each day in a typical teaching hospital”, explains Dr Hamblin-Brown. “It is a procedure prone to a multitude of errors due to reliance on paper that’s easily lost or verbal discussion that’s easily forgotten.” One of the most worrying findings in the research is that most handover takes place using a many different support systems; 35% are still using handwritten notes; 21% are using office documents such as Word and Excel; 10% write on whiteboards and a full 15% are using unofficial messaging apps like WhatsApp. Healthcare leaders reflect the same concerns as staff, but they specifically also want more access to patient information and better electronic systems. Digital platforms may be the only real solution to the challenges surrounding handover, with the ability to provide safe and secure access to handover information at the swipe of a screen that is neither lost nor forgotten. “We work in an industry that is failing to take seriously the dangers of handover. It is arguably the most common, and one of the most important, processes. We harm both staff and patients if we fail to address the dangers of handover,” concludes Dr Hamblin-Brown. *This paper is in pre-print and has not yet been peer-reviewed. -
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.
