Understanding the Types and Effects of Clinical Interruptions and Distractions Recorded in a Multihospital Patient Safety Reporting System

作者：Kathryn M. Kellogg, Joseph S. Puthumana, Allan Fong, Katharine T. Adams, Raj M. Ratwani · 发表于：Journal of Patient Safety · 年份：2018 · DOI：10.1097/pts.0000000000000513 · 被引用次数：28 · 研究领域：Patient Safety and Medication Errors、Hospital Admissions and Outcomes、Electronic Health Records Systems

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. 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. 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...