Proceedings of the Human Factors and Ergonomics Society Annual Meeting · 2008 · 21 citations · 16 references
Social SciencesAnesthesiologyPerioperative MedicineAnesthesiaMemoryPatient SafetyAnesthetic RecoveryMemory RetrievalPatient Safety In AnesthesiaProspective MemoryRecall MemoryAttentionInterruptionsPerioperative Patient SafetyProspective Memory AssessmentProspective Memory EncodingProspective Memory FailuresProspective Memory JudgmentsProspective Memory Retrieval
Interruptions have been associated with adverse events in healthcare. However, supporting studies are descriptive and atheoretical rather than explanatory, and they seldom show that interruptions compromise patient safety. Prospective memory may provide useful theoretical background. We analyzed video from a full-scale patient simulator for factors enhancing or inhibiting anesthesiologists' prospective memory performance. The critical task was to remember to cross check a unit of blood against the patient before administering the blood. All 12 participants were interrupted by the surgeon when the blood arrived. Only participants who self-initiated the retrieval (n = 3), or returned their full attention to the transfusion task and saw the blood bag label (n = 7), remembered the check. The result can be explained with findings from prospective memory literature.
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Transfusion errors in New York State: an analysis of 10 years' experience
Jeanne V. Linden, Kathleen Dorman Wagner, Anthony E. Voytovich et al. · Transfusion · 2000 · 412 citations
Medicine, Hematology, Mistake +8