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Interruptions Can Be Fatal

We’ve all heard of the distracted pilots who overshot the Minneapolis airport. But did you know that medical errors due to distraction place many people in danger every day?

A reader sent me a fascinating dispatch from the medical world on a series of San Francisco-area programs to reduce medical errors while nurses are dispensing medications. Nurses reduced their errors nearly 90 percent at nine Bay-area hospitals over the past year, and a key to the effort lay in new techniques to reduce distractions.

You can imagine what happens. Hospitals are busy places, with the level of care growing more complex by the day. A nurse dispensing medicine at bedside gets interrupted, mixes up one medicine for another, and the results can be fatal. Errors in administering medicine cause 400,000 preventable injuries in hospitals and $3.5 billion in extra medical costs annually, according to the Institute of Medicine.

The focus on distractions at Kaiser South San Francisco Medical Center began with orange vests – similar to those construction workers wear, according to an article in Nursezone, an online news site for the field. Quality-control nurses thought that wearing the vests as a kind of walking “do not disturb” sign could reduce interruptions during pill dispensing.

At first, floor nurses balked, seeing the vests as “cheesy” and “demeaning.” But first results showed that two units cut their errors in half in just four or five months simply by using the vests and educating nurses about reducing distractions.

The word spread throughout the hospital and across the Kaiser system, and a test of nine hospitals reduced medical dispensing distractions about 88 percent in the past year. The larger program includes many more safety steps from checking patient identity twice to turning up the lights and – my particular favorite – turning down the television. (I recall taking my then-two daughter to the dentist for the first time and watching amazed as the hygienist tried to give her a first brushing lesson with the tv blaring. Since then, I’ve always switch off the tv when a dentist or assistant come in the room.)

As a result of the intervention, giving medicines is “a more focused process,” says Suzi Kim, RN, BSN, and a staff nurse at Kaiser West Los Angeles hospital. Without interruptions, “we can think clearly.”

And if hospital staff can think clearly, perhaps they can do more to see and treat the whole human being. I hope so. As important as these anti-distraction programs are, procedures shouldn’t be the end of the story. While medical folks need to focus to do their work correctly and to problem-solve, they also need to restore focus to their interaction with the patient.

That’s the topic of my next blog, which will run tomorrow.

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  1. Feb 6, 20113:20 pm