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Perspectives on Safety
Interruptions and Distractions in Health Care
In Conversation With… Enrico Coiera, MB, BS, PhD
Dr. Coiera, a professor at the University of New South Wales, has extensively researched and written about clinical communication processes and information systems. We spoke with him about how interruptions and distractions in the clinical environment influence patient safety.
Listen to an audio excerpt of the interview
(.MP3 | 11.9 MB)
Interruptions and Distractions in Health Care: Improved Safety With Mindfulness
by Suzanne Beyea, RN, PhD
This piece describes the research around the effect of interruptions and distractions on health care safety and advocates for promoting and teaching mindfulness to address risks.
Cases & Commentaries
Despite multiple checks by physician, pharmacist, and nurse during the medication ordering, dispensing, and administration processes, a patient received a 10-fold overdose of an opioid medication and a code blue was called.
Annie Yang, PharmD, BCPS
CME/CEU credit available for this case
A woman with coronary artery disease, diabetes, and hypertension was admitted for a myocardial infarction. Following percutaneous coronary intervention, the patient had several runs of non-sustained ventricular tachycardia (NSVT) and later experienced a cardiac arrest secondary to sustained VT.
Jonathan P. Piccini, MD, MHS; L. Kristin Newby, MD, MHS; and Robert M. Califf, MD
A patient admitted for acute liver failure, acute renal failure, respiratory failure, and hepatic encephalopathy had a rectal tube placed to manage diarrhea. Two weeks into his hospitalization, dark red liquid stool was noted in the rectal tube, and the patient was found to have a large ulcerated area in the rectum, likely caused by the tube.
Karen Ousey, PhD, RGN