Distractions in the healthcare setting are common and a constant threat to patient safety. New technologies have increased the number and types of distractions occurring in healthcare facilities. The Pennsylvania Patient Safety Authority analyzed 1,015 reports that could be attributed to distraction. The majority of events were classified as medication errors (59.6%), followed by errors related to procedures, treatments or tests (27.8%). Thirteen events were reported that resulted in patient harm. Forty reports specifically mention distraction from phones, computers or other technologic devices contributing to errors.
Definition of Distraction
The definition of “distract” is “to draw or direct (as one’s attention) to a different object or in different directions at the same time. Distraction is especially harmful to humans functioning in situations that require a lot of thinking with large amounts of difficult and rapidly changing information. Such situations occur constantly in healthcare settings.
Distraction Reports in Pennsylvania
Of the 13 Serious Events (events resulting in harm to the patient) reported, the majority were split equally between medication errors and errors related to procedures, treatments or tests. Sixty-six percent (n=672) of reports describe distraction of nurses directly contributing to the events. Fewer reports identify the following individuals as the distracted parties: laboratory technician/phlebotomist (7.9%, n=80), pharmacist (6.7%, n=68), physician (5.3%, n=54), radiology technician (2.3%, n=23), secretary (1.4%, n=14), respiratory therapist (1.2%, n=12), nursing assistant (0.9%, n=9), nurse practitioner/nurse anesthetist/physician’s assistant (0.6%, n=6), and “other” (4.0%, n=41).
Source of Distraction
The majority of events do not directly identify the source of the distraction; however, the following terms appeared in the event reports (with their frequency provided in parenthesis): forgot (80.8%, n=820), distract (14.1%, n=143) and interrupt (7.3%, n=74). In general the narratives describe some element of patient care being forgotten without identification for the reason for the lapse of memory or attribute the reason for the memory lapse to a general cause, such as being “busy” (5.4%, n=55). As mentioned, 40 event reports (3.9%) specifically identify distractions from phones, computers or other technologic devices as contributing to errors.
What You Can Do to Avoid an Event Due to Distraction:
- The most important thing patients or loved ones can do to avoid the risk of errors due to distraction, is to take steps to create a quiet environment, and ask visitors and healthcare workers to do the same when receiving care.
- Turn off cell phones, televisions and other electronic devices when receiving care or having a conversation with your doctor, nurse or other healthcare workers.
- Don’t be afraid to ask healthcare workers who are interrupted during your care to repeat their explanation of the care you are receiving and to reconfirm your identity.
- Don’t be afraid to ask your doctor or nurse to repeat any medications and their doses being administered to you before allowing the medication to be given. Make sure they know who you are and what you are being medicated for.
- Ask your doctor or nurse to review your plan of care and take careful notes, or request a copy of the plan in writing.
- Ask healthcare workers who are picking you up to take you to a test (such as an x-ray) or other treatment (such as physical therapy) to stop and confirm the reason for the test or treatment, and to confirm your identity.
- Ask healthcare workers who are drawing your blood or about to perform a test or treatment to stop and confirm the type of test or treatment, the reason for the test or treatment, and your identity.
- Don’t be afraid to speak up if you feel you are not receiving the proper attention because of distractions. (e.g. another healthcare worker speaking with your nurse or doctor while you are being cared for, loud music, or talking).
- Make sure that you know the names of everyone involved in your care, especially the physician in charge of your care.
- In addition to your name, give healthcare professionals another identifier, such as your birth date, to confirm who you are. Make sure you do this often, particularly when another nurse or other healthcare worker takes over your care.
- Make sure you have someone with you that you trust to be your advocate. This person can ask questions you may not be able to if you are under sedation in the hospital or simply not well enough.
- Another important thing consumers can do is to maintain an up-to-date medication list.
- Make sure if you are being admitted into the hospital that you share your up-to-date medication list with your doctor/nurse so they know what medications you are on.
- Discuss with your doctor/nurse what medications you will be on while in the hospital and what medications you can take from home (if any).
- If you are uncomfortable with any part of the discussion regarding your medications, make sure you discuss those concerns with your doctor/nurse until you are satisfied with your medication plan while in the hospital.
- During your hospital stay, if you do not feel you are being properly medicated, make sure you discuss your concerns with your doctor/nurse or a nurse manager until you are satisfied.
- Do not take any of your medications from home, unless those medications AND the correct dose have been approved by your doctor/nurse.
- Don’t be afraid to ask questions regarding your medications, especially during your hospital stay. It is important that you/caregiver know details regarding your medication plan especially while in the hospital.
- If you are given permission to take medications from home while in the hospital, make sure you understand the amount of the drug you should be taking each day. It may be different than what you would normally take at home.
For more information about the risks of distractions while using the healthcare system, go to the March 2013 Patient Safety Advisory article, “Distractions and Their Impact on Patient Safety” at the Authority’s website www.patientsafetyauthority.org.