Distracted Doctoring and Patient Safety: Lessons Learned

With the addition of computers, tablets and smart phones to the bedside, physicians and nurses are multi-tasking more and more. While doing more than one task at a time can lead to efficiencies in care, it can also lead to distraction and medical errors. Accreditation Director Steve Chinn cautions providers to be present in the moment when caring for patents. 

The connection between distracted and multi-tasking doctors and medical errors is well documented. A recent New York Times article that cites Stanford's Abraham Verghese and Charles Prober discusses the use of computers and handheld devices as tools that help clinicians, but also lead to further distraction and multi-tasking. As demand for improved patient flow, rapid turnaround times and multiple steps in even the most basic patient care processes become a greater reality, so too will opportunities for further distraction by the medical staff.

An example of this point is a recent event reported through the Stanford Alerts for Events (SAFE) reporting system. A physician was busy trying to complete progress and consult notes on his patients for the day, while waiting to get a call back on a page that he had placed. Realizing that there were orders that needed to be put in on patient A, the physician inadvertently placed a medication order into patient B's record, which was opened in EPIC. The staff complied immediately with the order, with patient B getting the medication intended for patient A. Fortunately, patient B did not get injured by the event. But the root cause of this error was the physician's momentary distraction while trying to do several routine things at once.

Another event occurred in a very busy procedural area, when an implant designated for patient C that was sitting on a shelf with other implants was inadvertently placed into patient D. When the event was reviewed, one contributing factor was multi-tasking by the physician and staff to facilitate the room setup and getting the patient ready. In this example, a momentary distraction in the physician and staff's focus led to an oversight in confirming the right patient with the correct implant. The incorrect implant was immediately identified and corrected by the physician without harm to patient D.

Not one of the physicians or the staff involved in either of these two events woke up that morning thinking, "I am going to do harm to my patients." The Hippocratic Oath we all took clearly states that position. However, bad things happen to good patients and we all have to take a moment, especially when multi-tasking, to do a quick double check. 

We understand the need for speed, especially with what is happening in health care today. The hospital does not want to ban text messaging or the use of PDAs or smart phones at the bedside as some hospitals have done. So we ask that you take that momentary pause whenever you are doing multiple functions, no matter how routine they may be. This can save you and your patients a lot of heartache down the road.

For additional information about Stanford Hospital & Clinics' patient safety program or to suggestion improvements, please contact Steve Chinn at sdchinn@stanfordmed.org.

By Steve Chinn, DPM, MS, MBA, Director, Accreditation and Regulatory Affairs