The Case

A young woman with morbid obesity was scheduled for cardiac catheterization to evaluate shortness of breath and chest pain. A decision was made to use a radial artery approach. Positioning the patient appropriately was challenging because she could not move easily. After multiple attempts, the team was able to access her radial artery. After the catheter was inserted, the patient began to experience increasing pain and pressure in both her arm and her chest. The team proceeded quickly with the procedure, but they hesitated to administer additional pain medication given the patient's body habitus and concern for respiratory suppression. Anesthesia was not consulted.

Review of the angiogram demonstrated the presence of an air embolism in the left coronary artery, caused by air being introduced into the patient's radial artery during the catheter insertion. It became clear that, because of the procedure's difficulty, the cardiac technician controlling the syringe for injecting dye failed to hold the syringe at the proper angle to prevent an air bubble from being introduced into the patient's vessel. When the air embolism was recognized, appropriate treatment protocols were implemented. The patient was ultimately transferred to a higher level of care, treated appropriately, and discharged from the hospital several days later.

Further review revealed that the team was under significant time pressure to perform the procedure, and many members were fatigued, as it had been a long day without breaks. Music playing in the background may also have created a distraction. In addition, during the procedure a Code Blue had been called in the room next door, which meant that several key personnel were not present for this patient's catheterization.

The Commentary

Commentary by Jamie M. Robertson, PhD, MPH, and Charles N. Pozner, MD

Distractions in the clinical environment play a key role in medical errors. In addition to shifting attention away from patient care, distractions negatively impact teamwork and communication.(1) Distractions take many forms, including background music, overhead paging and announcements, alarms from medical equipment, extraneous conversations, and staff entering and leaving the room.

All team members should make an effort to limit distractions, especially those that are within their control. While some distractions are inevitable in a fast-paced clinical environment, others, such as music and unnecessary conversation, can be avoided. When noise beyond conversation essential to patient care is present, requests for information or equipment have to be repeated frequently (2), which leads to delays in providing care and may prevent members of the team from hearing critical pieces of information. Interruptions—another type of distraction—result in increased stress, fatigue, and errors.(3) In this case, it was essential that team members left the room to attend the Code Blue next door, but their departure interrupted the usual processes and workflow of the procedure room. Distractions and frequent task-shifting play a role in the development of fatigue.(2) Common among clinicians and other health care workers in hospital settings, fatigue may lead to a delay in response time and contribute to medical errors.(4)

Interruptions are an inevitable part of clinical practice. Many cognitive strategies can be used to ensure that interruptions, when they do occur, do not adversely impact patient care.(5) A small pause before resuming the initial activity to allow for mental preparation to reenter the task at hand can be useful. This small time-out can be done individually or by all team members as a mini procedural pause. Additionally, creating times during procedures deemed "no interruption zones" allows for critical stages of procedures that require undivided attention to proceed without interruption.

Although avoiding distractions altogether is virtually impossible, care teams should try to prevent and address distractions as they occur, especially during critical parts of a procedure or if a patient is at increased risk for adverse outcomes due to comorbidities or clinical instability. In this case, the team likely did not have control over the Code Blue that was called and the ensuing loss of staff. However, asking for music to be turned down or even turned off would have been an easy solution to reduce distractions.

In addition to distractions, clinical teams are frequently confronted with pressure to turn over procedural rooms, such as catheterization laboratories, quickly. Cases are usually booked with little room for delay and staff may have work-hour restrictions that put increased pressure on physicians to get through procedures quickly and efficiently. Procedural time-outs have been successful in helping team members develop a shared mental model at the start of the procedure.(6) Some groups have implemented the use of time-out protocols when a team member feels like the plan has changed or when unexpected complications arise, such as in this case, where obtaining access was difficult. These can be initiated by any team member, at any time, to ensure that everyone has a chance to pause and reorient themselves to the procedure. This pause also encourages all individuals present to speak up about potential patient safety threats.

Under ideal circumstances in this case, the team would have begun by trying to prevent as many distractions as possible. Although the team was pressured by a late start and the need for room turnover, turning off the music and taking a moment to allow everyone to focus on the task at hand might have helped improve the care of the patient. When positioning the patient and obtaining access proved challenging, a time-out called by a team member could have allowed for discussion and the development of a plan that may have helped prevent the error that resulted in the air embolism. When key personnel were called away, the remaining members should have assessed whether they had the expertise and appropriate staff required to move forward with the procedure safely. If necessary, additional help should have been called in to assist with the catheterization. A number of human factors design principles could be useful in preventing these interruptions and distractions. Observational analysis of flow interruptions in the catheterization suite could identify areas where consistent disruptions take place and highlight areas for possible improvement.(7) Improving the setup of the room, equipment availability, and minimization of distractions, such as alarms and overhead paging, would increase team members' focus and communication.

Team training programs, often utilizing simulation, can be a helpful way to reduce the risk of error by teaching team members how to respond appropriately in stressful situations.(8) These programs often focus on building effective communication skills and creating a work environment in which all team members are comfortable voicing their concerns. By fostering an environment of trust and support, team training has the potential to reduce threats to patient safety. The team working in the cardiac catheterization laboratory described in this case could consider using a simulation team training program to work on communication skills and minimizing distractions under stressful circumstances.

The use of checklists in clinical environments increases adherence to protocols, reduces complications, and lowers mortality rates in a number of high-risk clinical settings.(9,10) When individuals have an increased cognitive load due to interruptions, distractions, or stressful events, the use of checklists can help prompt team members to think through all options, complete tasks in the appropriate order, and remember details of procedures they may not frequently perform. Explicit, step-by-step instructions presented in an easy-to-follow manner provide the best chance for enhancing performance and decision-making among clinicians.(11)

Take-Home Points

• Distractions in the clinical setting should be minimized to ensure that team members are able to focus on the task at hand.
• Implementing time-outs and/or procedural pauses can help mitigate the adverse impact of interruptions on patient care.
• Team training programs, often utilizing simulation, can help minimize the risk of error by teaching team members how to respond appropriately in stressful situations.
• The use of checklists in clinical environments increases adherence to protocols, reduces complications, and lowers mortality rates in a number of high-risk clinical settings; checklists can be used to improve patient safety in settings where interruptions and distractions occur frequently.

Jamie M. Robertson, PhD, MPH Assistant Director, Simulation-Based Learning STRATUS Center for Medical Simulation, Brigham and Women's Hospital Instructor, Emergency Medicine Department of Emergency Medicine, Harvard Medical School

Charles N. Pozner, MD Executive Director STRATUS Center for Medical Simulation, Brigham and Women's Hospital Associate Professor, Emergency Medicine Department of Emergency Medicine, Harvard Medical School

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