The Science Journal of the American Association for Respiratory Care

2012 OPEN FORUM Abstracts


Deborah A. Maglionico1,2, Salvatore A. Sanders2, Teresa A. Volsko1,2; 1Respiratory Care, Akron ChildrenÂ’s Hospital, Akron, OH; 2Health Professions, Youngstown State University, Youngstown, OH

BACKGROUND: The Joint Commission and the Department of Veterans Affairs National Center for Patient Safety in America reported communication failure is the primary cause of patient safety events or near miss incidents. The study objective was to determine the effects interruptions during shift report had on patient safety. We hypothesize that interruptions occurring during shift report will contribute to safety events which reach the patient or result in a near miss event. METHODS: A nine question survey collected data on the incidence and type of interruptions occurring during morning and evening shift report. Information regarding patient acuity, staffing levels, near miss incidents and safety events which reached the patient was ascertained. The anonymous and confidential questionnaire was distributed to respiratory therapists assigned to the neonatal and pediatric intensive care units at a tertiary care ChildrenÂ’s Hospital. Each completed survey was placed in a sealed letter size envelope prior to hand delivery to the principle investigator. The envelopes containing the returned surveys were not opened until the close of the 4 week study period. RESULTS: Fifty three surveys were completed yielding a 40% response rate. Interruptions occurred more frequently in the morning (72.22%), compared to evening (47.62%) shift. Shift report was interrupted more often in the NICU (71%) than the PICU (29%). In all cases, a therapist participating in report was called to the bedside to reposition an endotracheal tube (19%), adjust ventilator settings (35%), set-up and troubleshoot equipment (12%), administer medication (4%), assess patient or participate in other forms of care at the bedside (30%). Staffing was at threshold 67% of the time and one below threshold 33% of the time. Interruptions occurring when staffing was below threshold resulted in a termination of report. Workload data are found in Table 1. Eleven errors occurred during the study period. Four errors reached the patient and resulted in a missed therapy, five documentation errors occurred and wrong information was provided on two patients during report that resulted in near miss safety events. CONCLUSIONS: Frequent interruptions during shift report led to miscommunication and contributed to safety events which reached the patient. Sponsored Research - None The type and frequency of interruptions that occurred during shift report.