Prospective memory failures as an unexplored threat to patient safety: results from a pilot study using patient simulators to investigate the missed execution of intentions

Dieckmann, Peter; Reddersen, Silke; Wehner, Theo; Rall, Marcus

doi:10.1080/00140130600568782

Cited by 58 publications

(29 citation statements)

References 25 publications

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“…Cognitive failure, conscientiousness and safety compliance Error in action execution occurs in routine tasks that have been done without error many times (Broadbent, Cooper, Fitzgerald, & Parkes, 1982;Klumb, 1995), thus a mostly avoidable threat is placed on patient safety (Dieckmann, Reddersen, Wehner, & Rall, 2006). Not only interruptions at work but also safety compliance and conscientiousness may relate to error.…”

Section: Workflow Interruptions As a Hindrance Stressormentioning

confidence: 99%

Workflow interruptions, cognitive failure and near-accidents in health care

Elfering

Grebner

Ebener

2014

Psychology, Health & Medicine

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Errors are frequent in health care. A specific model was tested that affirms failure in cognitive action regulation to mediate the influence of nurses' workflow interruptions and safety conscientiousness on near-accidents in health care. One hundred and sixty-five nurses from seven Swiss hospitals participated in a questionnaire survey. Structural equation modelling confirmed the hypothesised mediation model. Cognitive failure in action regulation significantly mediated the influence of workflow interruptions on near-accidents (p < .05). An indirect path from conscientiousness to near-accidents via cognitive failure in action regulation was also significant (p < .05). Compliance with safety regulations was significantly related to cognitive failure and near-accidents; moreover, cognitive failure mediated the association between compliance and near-accidents (p < .05). Contrary to expectations, compliance with safety regulations was not related to workflow interruptions. Workflow interruptions caused by colleagues, patients and organisational constraints are likely to trigger errors in nursing. Work redesign is recommended to reduce cognitive failure and improve safety of nurses and patients.

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Section: Workflow Interruptions As a Hindrance Stressormentioning

confidence: 99%

Workflow interruptions, cognitive failure and near-accidents in health care

Elfering

Grebner

Ebener

2014

Psychology, Health & Medicine

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“…This phenomenon of involuntary automaticity is more likely to occur when workload is high, interruptions frequent, staff are stressed, fatigued, well acquainted and trust each others professional judgement (Toft and Mascie-Taylor 2005;James 2009). Furthermore, interruptions and distractions in the workplace may impair a pharmacist's prospective memory, resulting in the undetection of dispensing errors due to failure of the pharmacist to recall and execute each stage of their checking process (Dieckmann et al 2006;James 2009).…”

Section: Discussionmentioning

confidence: 99%

Understanding vs. competency: the case of accuracy checking dispensed medicines in pharmacy

James

Davies

Kinchin

et al. 2010

Adv in Health Sci Educ

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Ensuring the competence of healthcare professionals' is core to undergraduate and post-graduate education. Undergraduate pharmacy students and pre-registration graduates are required to demonstrate competence at dispensing and accuracy checking medicines. However, competence differs from understanding. This study determined the competence and understanding of undergraduate students and pharmacists at accuracy checking dispensed medicines. Third year undergraduate pharmacy students and first year post-graduate diploma pharmacists participated in the study, which involved an accuracy checking task and concept mapping exercise. Participants accuracy checked eight medicines which contained 13 dispensing errors and then constructed a concept map illustrating their understanding of the accuracy checking process. The error detection rates and types of dispensing errors detected by undergraduates and pharmacists were compared using Mann-Whitney and chi-square, respectively. Statistical significance was p ≤ 0.05. Concept maps were qualitatively analysed to identify structural typologies. Forty-one undergraduates and 78 pharmacists participated in the study. Pharmacists detected significantly more dispensing errors (85%) compared to the undergraduates (77%, p ≤ 0.001). Only one undergraduate and seven pharmacists detected all dispensing errors. The majority of concept maps were chains (undergraduates = 46%, n = 19; pharmacists = 45%, n = 35) and spokes (undergraduates = 54%, n = 22; pharmacists = 54%, n = 42) indicating surface learning. One pharmacist, who detected all dispensing errors in the accuracy checking exercise, created a networked map characteristic of deep learning. Undergraduate students and pharmacists demonstrated a degree of operational competence at detecting dispensing errors without fully understanding the accuracy checking process. Accuracy checking training should be improved at undergraduate and post-graduate level so that pharmacists are equipped with the knowledge and understanding to accurately check medicines and detect dispensing errors, thereby safeguarding patient safety.

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“…25,29,30 Because team members do not have to remember items when using the APIC, it serves as a tool for overcoming the limitations of prospective memory; that is, remembering to perform actions at the appropriate time. 31 Prospective memory is susceptible to failure (e.g., forgetting to check the suction device because of imposed time pressure) when disturbances occur.…”

Section: Discussionmentioning

confidence: 99%

An Anesthesia Preinduction Checklist to Improve Information Exchange, Knowledge of Critical Information, Perception of Safety, and Possibly Perception of Teamwork in Anesthesia Teams

Tscholl

Weiss

Kolbe

et al. 2016

Survey of Anesthesiology

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BACKGROUND: An anesthesia preinduction checklist (APIC) to be performed before anesthesia induction was introduced and evaluated with respect to 5 team-level outcomes, each being a surrogate end point for patient safety: information exchange (the percentage of checklist items exchanged by a team, out of 12 total items); knowledge of critical information (the percentage of critical information items out of 5 total items such as allergies, reported as known by the members of a team); team members' perceptions of safety (the median scores given by the members of a team on a continuous rating scale); their perception of teamwork (the median scores given by the members of a team on a continuous rating scale); and clinical performance (the percentage of completed items out of 14 required tasks, e.g., suction device checked). METHODS: A prospective interventional study comparing anesthesia teams using the APIC with a control group not using the APIC was performed using a multimethod design. Trained observers rated information exchange and clinical performance during on-site observations of anesthesia inductions. After the observations, each team member indicated the critical information items they knew and their perceptions of safety and teamwork. RESULTS: One hundred five teams using the APIC were compared with 100 teams not doing so. The medians of the team-level outcome scores in the APIC group versus the control group were as follows: information exchange: 100% vs 33% (P < 0.001), knowledge of critical information: 100% vs 90% (P < 0.001), perception of safety: 91% vs 84% (P < 0.001), perception of teamwork: 90% vs 86% (P = 0.028), and clinical performance: 93% vs 93% (P = 0.60). CONCLUSIONS: This study provides empirical evidence that the use of a preinduction checklist significantly improves information exchange, knowledge of critical information, and perception of safety in anesthesia teams-all parameters contributing to patient safety. There was a trend indicating improved perception of teamwork. The WHO Guidelines for Safe Surgery also encourage a formal inspection of the anesthetic equipment, breathing circuit, medications, and a patient's anesthetic risk before each case.The reason for introducing the separate anesthesia preinduction checklist (APIC), in addition to the already introduced WHO surgical safety checklist, was that the WHO surgical safety checklist contains only a few supercritical anesthesia items (e.g., checks of saturation sensor, but not electrocardiogram or blood pressure monitoring).In this study, we sought to evaluate whether the APIC complementing the WHO surgical safety checklist is suited to improve 5 team-level outcomes, each shown to be critical surrogate end points for patient safety: information exchange, knowledge of critical information, team members' perceptions of both safety and teamwork, and clinical performance. Figure 1 outlines the series of subitems assessed for the outcome scores: information exchange, knowledge of critical information, and clinical performance...

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Prospective memory failures as an unexplored threat to patient safety: results from a pilot study using patient simulators to investigate the missed execution of intentions

Cited by 58 publications

References 25 publications

Workflow interruptions, cognitive failure and near-accidents in health care

Workflow interruptions, cognitive failure and near-accidents in health care

Understanding vs. competency: the case of accuracy checking dispensed medicines in pharmacy

An Anesthesia Preinduction Checklist to Improve Information Exchange, Knowledge of Critical Information, Perception of Safety, and Possibly Perception of Teamwork in Anesthesia Teams

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