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May 21, 2013
Distractions and interruptions are frequent contributing factors to errors in all healthcare settings. But in the perioperative setting they are especially prone to result in errors that impact patient outcomes. Several recent papers have highlighted the many issues involved in producing interruptions and distractions in the perioperative setting.
Jacqueline Ross (Ross 2013) recently highlighted in an editorial those interruptions and distractions that often take place in the preoperative holding area, the OR, the PACU, and the several handoffs that take place among these areas. She correctly points out that many of these are likely not preventable but others are preventable. Two of the areas in which distractions might be prevented are OR traffic and use of wireless devices in these areas. She appropriately invokes the aviation concept of the “sterile cockpit” that we have used so often. During crucial portions of a procedure (eg. pre-op huddle, surgical timeout, induction, surgical incision, closure, debriefing, anesthesia emergence, etc.) there should be no extraneous conversations and all should focus on the task at hand. She suggests limiting the number of people entering or leaving the OR during those critical tasks.
She then reopens the controversial debate about cellphones (or other mobile electronic devices) in the OR (or other perioperative areas). That debate has been ongoing for quite some time now and, unfortunately, has so many pros and cons that resolution has been slow.
Shortly after the incident where 2 airline pilots overflew their destination because they had become so engrossed in their laptop computers, Dean raised the question of the need to ban personal computer use in the OR (Dean 2010). He cited the statistics on how reaction times are considerably longer while reading an e-mail or sending a text message than they would be if legally drunk. In our April 16, 2013 Patient Safety Tip of the Week “Distracted While Texting” we discussed the New York Times article on the potential patient safety issues related to distractions from electronic devices in hospitals (Richtel 2011). It describes things like a neurosurgeon making personal calls on a cell phone via wireless headset during an operation, and a nurse in the OR using an OR computer to check airline prices during an ongoing operation. It quoted an article from the journal Perfusion (Smith 2011) which found that 55 percent of technicians who monitor bypass machines acknowledged to researchers that they had talked on cellphones during heart surgery. Half said they had texted while in surgery. The NYT article also cites an article by anesthesiologist Dr. Peter Papadakos (Papadakos 2011). In that article he quotes an abstract presented at the 2011 annual meeting of the American Society of Anesthesiologists that nurse anesthetists and residents were distracted by something other than patient care in 54% of cases—even when they knew they were being watched! Most of what took their time were pleasure cruises on the Internet (abstract 1726).
Now a new study has looked at how background noise in the OR might interfere with surgical team communication (Way 2013). This study got quite a bit of press, probably because one of the background noises considered was music in the OR. In a simulated OR setting the investigators looked at the ability of 15 surgeons (who had normal hearing sensitivity) to understand and repeat words against a varying background of noises whether or not they were performing tasks. They found that the impact of noise is considerably greater when the participant is tasked. Moreover, the performance was poorer when the sentences were low in predictability. One can readily see from their results how background noise could interfere with the surgeon’s ability to understand communications during a critical task, particularly if the communication is not a predictable one. The authors conclude that to avoid possible miscommunication in the OR, attempts should be made to reduce ambient noise levels. The authors plan on extending the study to include other members of the surgical team and to also assess the impact in surgeons who have some hearing impairment to start with.
Our July 31, 2012 Patient Safety Tip of the Week “Surgical Case Duration and Miscommunications” highlighted a study (Feuerbacher 2012) of surgical residents in an OR simulator environment that clearly demonstrated the impact of OR distractions and interruptions (ORDI’s) in producing surgical errors. Eight of eighteen participants committed significant surgical errors during simulated laparoscopic cholecystectomy when distracted or interrupted, compared to only one of eighteen who were not interrupted or distracted.
Interruptions increase the likelihood of errors because we must refocus to resume where we had left off in our task prior to the interruption. It turns out that even very brief interruptions can have a marked impact on our ability to resume those tasks. Altmann and colleagues recently studied the effect of short interruptions on performance of a task that required participants to maintain their place in a sequence of steps (Altmann 2013). Interruptions averaging just 2.8 s long doubled the rate of sequence errors and interruptions averaging 4.4 s long tripled the rate of sequence errors on post-interruption trials relative to baseline trials.
Think of all the interruptions that occur during a surgical procedure. Even those short interruptions, especially if they occur during critical parts of procedures or when novel or unexpected events have occurred, could profoundly increase the odds of errors and untoward patient outcomes.
Ironically, most of us don’t even recognize when and how often we are being distracted. There are a couple ways to get a better handle on that, though both are resource-intensive. One is to do video/audio recording in the OR (or other perioperative setting) and then play it back for all parties in a constructive fashion so they can see how well (or not so well) they communicated and how distractions interfered with their communications.
The other is to use the direct observational methodology that we mentioned recently in several columns. That method relies on having specially trained observers within the perioperative setting to observe and record all events taking place (and it usually requires more than one observer at a time). In our November 27, 2012 Patient Safety Tip of the Week “Dealing with Distractions” we noted a study that used direct observation of anesthetists and anesthesiologists as they cared for patients from the time the anesthetist and patient entered the anesthetic room until recovery (Campbell 2012). They found an average of 0.23 interruptions per minute overall but the interruption rate differed during various stages of the overall process. Interruptions came from a variety of sources (internal team members, external team members, equipment-related issues, workspace design issues, noise, teaching responsibilities, patient-related problems, and items such as pagers and mobile phones). The authors did note that not all interruptions have negative impact. In fact, 3.3% had a positive impact (i.e. the distraction or interruption facilitated either the procedure or the safety of the patient). They went on to discuss strategies used by the anesthesia personnel for coping with distractions and interruptions. We also noted the utility of the direct observational methodology in our October 23, 2012 Patient Safety Tip of the Week “Latent Factors Lurking in the OR”.
We’ve done a number of columns on the deleterious effects of interruptions and distractions for physicians, nurses, pharmacists and others:
Ross J. Distractions and Interruptions in the Perianesthesia Environment: A Real Threat to Patient Safety. J Perianesth Nursing 2013; 28(1): 38-39
Dean S. Distractions in the Operating Room: Should the Use of Personal Computers Be Banned during the Administration of Anesthesia? APSF Newletter 2010; 25(1): 19 Spring 2010
Richtel M. As Doctors Use More Devices, Potential for Distraction Grows.,New York Times, December 14, 2011
Smith T, Darling E, Searles B. 2010 Survey on cell phone use while performing cardiopulmonary bypass. Perfusion 2011; 26(5): 375-380
Papadakos PJ. Electronic Distraction: An Unmeasured Variable in Modern Medicine. Anesthesiology News 2011; 37:11 November 2011
Way TJ, Long A, Weihing J, et al. Effect of Noise on Auditory Processing in the Operating Room. J Am Coll Surg 2013; 216(5): 933-938
Feuerbacher RL, Funk KH, Spight DH, et al. Realistic Distractions and Interruptions That Impair Simulated Surgical Performance by Novice Surgeons. Arch Surg 2012; (): 1-5 published online first July 2012
Altmann EM, Trafton JG, Hambrick DZ. Momentary Interruptions Can Derail the Train of Thought. Journal of Experimental Psychology: General, Jan 7 , 2013
Campbell G, Arfanis K, Smith AF. Distraction and interruption in anaesthetic practice.
Br. J. Anaesth 2012; 109(5): 707-715
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Our February 2013 What’s New in the Patient Safety World column “Joint Commission Proposes New 2014 National Patient Safety Goal” discussed the newly proposed NPSG dealing with alarms. Joint Commission has now published a Sentinel Event Alert dealing with alarms (Joint Commission 2013a).
We’ve mentioned before that we often make amicable bets with CEO’s when we enter their facilities that we will find within a specified timeframe some alarms that have been disabled or otherwise manipulated. It’s a problem that is obviously widespread and dangerous. But its roots are many and deep. We have far too many alarms and this leads to the phenomenon of alarm fatigue. The new Joint Commission sentinel event alert cites the statistic that between 85% and 99% of alarm signals do not require clinical intervention. Their sentinel event database has 98 alarm-related events over a little more than 3 years, 80 of which resulted inpatient death. Major contributing factors included absent or inadequate alarm systems, improper alarm settings, inaudible alarms, alarm settings inappropriately turned off, and others. They also cite events and contributing factors and recommendations from studies by ECRI Institute and the FDA and the Association for the Advancement of Medical Instrumentation.
They provide 11 recommendations that are in keeping with the newly proposed NPSG. These include involving leadership and management in developing programs of alarm management and oversight, doing an inventory of all alarms (and eliminating those not necessary), establishing guidelines for alarm settings and individualizing them for each patient or patient type, and regularly inspecting, checking and maintaining all alarms. They stress ongoing education and updates on alarmed medical devices. They recommend a multidisciplinary team lead the oversight and provide lessons learned from other organizations. They recommend using single use sensors (such as ECG leads) to reduce nuisance alarm signals. They also recommend checking the acoustics of the environment to assure alarms will be audible.
Regarding the latter recommendation we also suggest the environmental design be checked to ensure that it does not promote turning alarm volumes down. One of our earliest columns on alarm issues (April 2, 2007 Patient Safety Tip of the Week “More Alarm Issues”) focused on a faulty design where proximity of the ECG monitoring system to the nursing charting area often led to nurses and others turning down the volumes, eventually leading to a disastrous consequence.
Checking alarms should be a regular component of your Patient Safety Walk Rounds. More importantly, it should be something your staff does daily on every unit that utilizes alarms of any type. Some units even do it on every shift. And when you find alarms that have been disabled or otherwise manipulated make sure you find out why. Such actions always have an underlying root cause that must be addressed.
You should include alarm status as part of your structured handoff tool used at changes of shift. And alarm status must be included in your “Ticket to Ride” tool for in-hospital transports (eg. to radiology).
We also strongly recommend that any time you set up a new piece of equipment on a patient you use a checklist specific to that piece of equipment that forces you to verify that all alarms are appropriately set and functional and that parameters chosen are appropriate. We also recommend you review some of the useful tips we’ve included in our February 23, 2010 Patient Safety Tip of the Week “Alarm Issues in the News Again” and the several other columns noted below.
Prior Patient Safety Tips of the Week pertaining to alarm-related issues:
The Joint Commission. Medical device alarm safety in hospitals. The Joint Commission Sentinel Event Alert 2013; 50: 1-3 April 8, 2013
The Joint Commission. Proposed 2014 National Patient Safety Goal on Alarm Management. January 15, 2013
In our September 11, 2012 Patient Safety Tip of the Week “In Search of the Ideal Early Warning Score” we discussed a recommendation in the UK for hospitals to adopt a national early warning score system. In February 2013 Ireland became the first country to adopt such a nationwide system (Press Release 2013).
The guideline applies to all adult patients in acute care hospital settings, including outpatients and day treatment patients receiving invasive procedures or moderate sedation. It does not apply to pediatric or obstetrical patients, for whom different physiological parameters apply. There are 60 recommendations in the guidelines. Both a summary of the guideline and a full text version are available.
But a new study points out one of the flaws in most early warning systems: incomplete recording of key elements in the early warning score (Hands 2013). Vital signs are key elements in all such scores but very often they are recorded inconsistently. The authors found only partial adherence to the vital signs monitoring protocol. Sicker patients were more likely to have vital signs measured overnight, but even their observations were often not followed by timely repeat assessments. The authors felt that the observed pattern of monitoring may reflect the impact of competing clinical priorities.
The whole point of early warning scores is to pick up on more subtle signs of clinical deterioration so that early interventions can take place. It is important that the data elements chosen for such scores will, in fact, be regularly assessed and used in the early warning score.
Press Release. Minister for Health, Dr. James Reilly TD endorses and launches first National Clinical Guideline: National Early Warning Score. 18th February 2013
Patient Safety Initiative in Ireland. National Clinical Effectiveness Committee. National Early Warning Score. National Clinical Guideline No. 1. An Roinn Slainte Department of Health. February 2013
full text of the guideline
Hands C, Reid E, Meredith P, et al. Patterns in the recording of vital signs and early warning scores: compliance with a clinical escalation protocol. BMJ Qual Saf 2013; published online first 19 April 2013 doi:10.1136/bmjqs-2013-001954
The BBC has a great video “How to Avoid Mistakes in Surgery” that is now on YouTube. It’s an hour-long presentation that incorporates human factors principles into a variety of surgical scenarios. It begins with a case where a patient dies because the team focused on trying to intubate an obstructed airway and overlooked performng an emergency tracheostomy. It emphasizes how we focus our attention and may develop tunnel vision and lose situational awareness. It also shows how both lack of a person in charge and the authority gradient come into play (a nurse brought an emergency tracheostomy kit into the OR but did not speak up to suggest it be used). It gives great examples from other industries about human factors involved in emergent situations. It shows firefighters going through a simulated exercise emphasizing the importance of situational awareness. It includes Atul Gawande discussing the WHO Surgical Safety Checklist. It has good segments on the value of simulation and handoffs, again using analogies with Formula-1 race cars. Then it talks about dealing with emergencies for which you have never been trained, using Sully Sullenberger and the plane he landed safely on the Hudson River. It even includes neurophysiological substrates of how we think about errors and how a positive attitude about errors can foster the sort of quick solutions used by people like Sullenberger.
It’s a very well done presentation that really shows how human factors should be incorporated into our every day healthcare world. It’s an hour but one that will be well spent.
BBC Horizon 2013 – How to Avoid Mistakes in Surgery
Diagnostic error has always lurked in the background of the patient safety movement. But in the past several years there has been a renewed focus on diagnostic error. Now researchers from Johns Hopkins have analyzed diagnosis-related claims from the National Practitioner Data Bank (NPDB) and the results are eye-opening (Tehrani 2013). They found that among malpractice claims, diagnostic errors appear to be the most common, most costly and most dangerous of medical mistakes. Diagnostic errors include failure to diagnose, wrong diagnosis, delayed diagnosis, failure to follow up on tests, etc.
Analyzing over 350,000 paid claims over a 25-year period they found diagnostic errors accounted for 28.6% of the claims, more than any other category. Moreover, they accounted for 35.2% of the total payments.
Diagnostic errors more often resulted in death than other categories of malpractice claims. Significantly, they also found that disability as a result of diagnostic error was substantial. The authors note that this means previous estimates of the impact of diagnostic errors were probably significant underestimates because they were based largely on autopsy studies. Outpatient diagnostic errors leading to claims were over twice as common as inpatient diagnostic errors, though the latter were more likely to lead to fatal outcomes.
What’s ironic is that we often don’t even know about our diagnostic errors unless there is a malpractice claim. Substantial periods of time typically elapse before it becomes apparent that a diagnostic error occurred. And it usually becomes apparent when the patient is elsewhere (another physician’s office, an emergency room, another hospital, etc.). An angry patient may call you and let you know about it but more often the patient simply loses confidence in you and just never returns to you for care. And if we don’t get feedback about our diagnostic errors or diagnostic accuracy we often get overconfident in our own abilities. And, of course, many of our diagnostic errors do not result in patient harm at all. However, they may result in delays and inconveniences.
In our April 2013 What’s New in the Patient Safety World column “AHRQ Recommended Patient Safety Practices” we noted the ten strategies identified by the AHRQ project that are "strongly encouraged" for adoption based on the strength and quality of evidence and twelve other strategies "encouraged" for adoption based on a slightly lesser strength and quality of evidence. Strategies targeted at diagnostic errors did not make the final list but the supplement with the evidence reviews (Annals of Internal Medicine 2013) did provide a systematic review of those strategies targeted at diagnostic errors (McDonald 2013). One is really struck by the paucity of good research on interventions to reduce diagnostic errors or at least identify them before they lead to patient harm or inconvenience.
Our March 2013 What’s New in the Patient Safety World column “Diagnostic Error in Primary Care” focused on a study using a trigger tool methodology to help identify diagnostic errors in primary care settings (Singh 2013). Singh and colleagues make several salient points about interventions to prevent diagnostic errors. First, given the wide variety of conditions and presenting symptoms they found in their study it is very unlikely that focusing solely on specific presentations will be successful in reducing overall errors. They note that most of the breakdowns occurred in the clinical encounter, perhaps with time pressures and short encounters contributing to inadequate decision making. Further yet they note that the trend toward team care and the patient-centered medical home may not result in the level of cognitive support needed for complex decision making. And the current levels of technological decision support for diagnosis are not readily available in most of today’s electronic medical records.
In our September 28, 2010 Patient Safety Tip of the Week “Diagnostic Error” we highlighted a review of diagnostic error by the Pennsylvania Patient Safety Authority. The PPSA review also provides a couple nice tools to help clinicians identify and avoid diagnostic errors. One is a chart audit tool to help identify errors adopted from the article by Schiff et al (Schiff 2009). The other is a simple checklist the clinician can use to help focus the things he/she needs to do to in each case avoid diagnostic errors.
We hope you’ll look at some of our prior columns on diagnostic error, listed below, that highlight some of the work by some excellent researchers (like Mark Graber, Pat Croskerry, John Ely, Gordon Schiff, Hardeep Singh, Jerry Groopman, Gary Klein and many others) on the way clinicians think and the cognitive biases that are important in diagnostic errors. Now that these recent studies have identified the scope of the problem it is time to begin focusing on ways to mitigate the problem.
Some of our prior Patient Safety Tips of the Week on diagnostic error:
Tehrani ASS, Lee HW, Mathews SC, et al. 25-Year summary of US malpractice claims for diagnostic errors 1986–2010: an analysis from the National Practitioner Data Bank
BMJ Qual Saf 2013; Published online 22 April 2013 doi:10.1136/bmjqs-2012-001550
Annals of Internal Medicine. Making Health Care Safer: A Critical Review of Evidence Supporting Strategies to Improve Patient Safety. Annals of Internal Medicine 2013; 158(5_Part_2)
McDonald KM, Matesic B, Contopoulos-Ioannidis DG, et al. Patient Safety Strategies Targeted at Diagnostic Errors: A Systematic Review. Ann Intern Med 2013; 158(5_Part_2): 381-389
Singh H, Giardina TD, Meyer AND, et al. Types and Origins of Diagnostic Errors in Primary Care Settings. JAMA Intern Med 2013; published online February 25, 2013
Pennsylvania Patient Safety Authority (PPSA). Diagnostic Error in Acute Care. Pa Patient Saf Advis 2010 Sep;7(3):76-86
Schiff GD, Hasan O, Kim S; et al. Diagnostic Error in Medicine: Analysis of 583 Physician-Reported Errors. Arch Intern Med, Nov 2009; 169: 1881 – 1887
DEER Taxonomy Chart Audit Tool
Pennsylvania Patient Safety Authority. A Physician Checklist for Diagnosis.
The controversy over perioperative use of beta blockers just won’t go away. We’ve addressed the issue in multiple columns (see the list at the end of today’s column). After several years in which we pushed for almost universal use of beta blockers perioperatively, publication of the POISE trial (Devereaux 2008) significantly changed things. You’ll recall that the POISE trial showed that, though preoperative beta blockers prevented 15 MI’s for every 1000 patients treated, there was an increased risk of stroke and an excess of 8 deaths per 1000 patients treated. Largely since that time recommendations have been to continue beta blockers in the perioperative period in patients previously taking them but most no longer begin them perioperatively in patients not previously taking them.
But there have been numerous criticisms of the POISE trial. Specifically, patients received fairly large doses of metoprolol shortly before their surgery and many have argued that starting beta blockers well in advance of surgery and titrating the dose slowly would not have produced the adverse outcomes seen in POISE.
There certainly are studies that demonstrate a continued need to continue beta blockers in patients previously taking them. Our November 2010 What’s New in the Patient Safety World column “More Perioperative Beta Blocker Controversy” noted some observational data (Wallace 2010) suggesting that perioperative beta blockade reduces mortality at both 30 days and one year. And that data reinforces that perioperative withdrawal of beta blockers increases mortality. In fact, the Wallace paper showed that beta blocker withdrawal almost quadrupled the 30-day mortality rate and almost doubled the 1-year mortality rate. In our November 2012 What’s New in the Patient Safety World column “Beta Blockers Losing Their Luster?” we noted an observational study supporting the current practice of continuing beta blockers perioperatively in patients who had been taking them prior to their surgery (Kwon 2012). This study, part of a collaborative quality improvement project in Washington state, found that failure to continue beta blockers in patients previously on them almost doubled their rate of adverse events within 90 days after noncardiac surgery.
We previously joked that one pro-beta-blocker article always engenders another anti-beta-blocker article and vice versa! That trend continues.
Now a new observational study again raises the question of utility of perioperative beta blockers in patients undergoing noncardiac surgery (London 2013). The researchers looked at a large population of patients in 104 VA medical centers who underwent major noncardiac surgery and matched them to a control group using propensity scores. They found that among propensity-matched patients undergoing noncardiac, nonvascular surgery, perioperative β-blocker exposure was associated with lower rates of 30-day all-cause mortality in patients with 2 or more Revised Cardiac Risk Index factors.
This study again points out the need for a large randomized controlled trial, similar to the POISE trial that looks at whether the slower, titrated perioperative beta blocker use is of benefit.
Our prior columns on perioperative use of beta blockers:
November 20, 2007 “New Evidence Questions Perioperative Beta Blocker Use”
November 4, 2008 “Beta Blockers Take More Hits”
December 2009 “Updated Perioperative Beta Blocker Guidelines”
November 2010 “More Perioperative Beta Blocker Controversy”).
November 2012 “Beta Blockers Losing Their Luster?”
Devereaux PJ, Yang H, Yusuf S, et al for the POISE Study Group. Effects of extended-release metoprolol succinate in patients undergoing non-cardiac surgery (POISE trial): a randomised controlled trial. Lancet 2008; 371(9627): 1839-1847
Wallace AW, Au S, Cason BA. Association of the Pattern of Use of Perioperative ß-Blockade and Postoperative Mortality. Anesthesiology 2010; 113(4): 794-805
Kwon S, Thompson R, Florencem M, et al. β-Blocker Continuation After Noncardiac SurgeryA Report From the Surgical Care and Outcomes Assessment Program
Arch Surg. 2012; 147(5): 467-473
London MJ, Hur K, Schwartz GG, Henderson WG. Association of Perioperative β-Blockade With Mortality and Cardiovascular Morbidity Following Major Noncardiac Surgery. JAMA 2013; 309(16): 1704-1713
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