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Abstract

Up to 98,000 patients die annually in U.S. hospitals due to human error. Despite epidemiological studies demonstrating the severity of this problem it is still unclear what the contributing factors to human error are. However, in aviation one contributor to accidents is task interruptions. The present study examined the frequency and impact of task interruptions in the Intensive Care Unit.

Observational data were collected in the ICU by shadowing nurses. During the 34 hours of observation, 1138 nurse activities were observed, of which 29.4% were interrupted. Consequences of an interruption for the primary task can be abandoning its completion or omissions of some of the tasks steps. The conditional probability that an interrupted task was abandoned was p(abandoned | interrupted) = .12, where the omission of steps of the primary task had a conditional probability of p(omission | interrupted) = .015. A total of six cases that created patient hazards were observed where in five of these cases an interruption preceded directly.

The results of the present study indicate that interruptions in the ICU are frequent and are likely to have a negative impact on patient safety.

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References

Andrews

Stocking

Krizek

et al. (1997). An alternative strategy for studying adverse events in medical care. Lancet, 349, 309–313

Chisholm

Collison

Nelson

Cordell

(2000). Emergency department workplace interruptions: Are emergency physicians ‘interrupt-driven’ and ‘multitasking’? Acad Emerg Med. 7, 1239–1243

Coiera

Jayasuriya

Hardy

Bannan

Thorpe

(2002). Communication loads on clinical staff in the emergency department. Med J Australia, 176, 415–418.

Donchin

Seagull

(2002). The hostile environment of the intensive care unit. Current Opinion in Critical Care. 8, 316–320.

Harris

(1984). Remembering to do things: A forgotten topic. In Harris

Morris

Everyday memory, actions, and absent-mindedness. New York: Academic Press.

Institute of Medicine (2000). To err is human: building a safer health system. Kohn

L.T.

Corrigan

J.M.

Donaldson

M.S.

Washington D.C.: National Academy Press

Peterson

Bergin

(1999). Pharmacist's attitudes towards dispensing errors: Their causes and prevention. J Clin Pharm Ther., 24, 57–71.

Reason

(1990). Human Error. Cambridge University Press.

Rothschild

Landrigan

Cronin

(2005). The critical care study: The incidence and nature of adverse events and serious medical errors in intensive care. Crit Care Med, 33, 1694–1700

The frequency and impact of task interruptions in the ICU

Abstract

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References