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Belly Aches and Other Distractions

In the last blog post I talked about distractions in the cockpit and the operating room.  Let’s follow up on that and see how distractions can have a potentially negative impact the entire team around us.  You might be OK with the loud music but other critical team members are getting distracted and that impacts the final outcome.  My kids and I used to play a driving game to see who could be the first to spot the driver of another car on their cell.  Eventually there were so many offenders, we changed the game  to spot those drivers NOT on their phone.  After that became pretty rare we then tried to spot the cars driven by talkers from a distance without looking in the window.  One kid would point out the car and then the other would look at the driver to check.

My son got pretty good at this– he could just “tell” by watching the car.  He had developed an ability to spot the markers of distracted driving.  One giveaway was going too slow (regardless of how smart you are you just can’t do two complex tasks at the same time without performance degrading on both).  Also he said the cars drifted across the lanes – sometimes into on-coming traffic until some honked. He said a real give-way was when they missed traffic signs and traffic lights and that they were just “bad drivers”.

He was right, and this has become such a problem that the NTSB has issued a recent recommendation to adopt federal laws banning use of cell phones while driving  Their statistics indicate that there is one traffic accident every 10 seconds of every day based on distracted driving – about 8,000 a day.  There were 33,788 highway fatalities last year and the use of a cell phone increases the risk of a fatal crash four-fold.  Sending text messages while driving increases the risk of a crash 23-fold!  Talking on a cell phone – even hands free – reduces drivers’ cognitive capabilities by 40% according to the Carnegie Mellon’s Center for Cognitive Brain Imaging giving the driver a reaction time equal to a blood alcohol level of 0.08 – which is legally drunk.   The human brain is not neurologically capable of as much “multitasking” as we believe and making an error by getting distracted from a critical task is a universal result of overloading our internal hard drives.  Distractions are important Error Producing Conditions.

So let’s play another game and call all the drivers on the road around you your “driving team”.  Do you really want these distracted players on your team?  Not only are they not paying attention but equally important is you can’t count on them to follow the rules of the road.  You also can’t predict their behavior which is a critical element of high reliability team skills.  But perhaps the most important point is that they are not prepared to act correctly in an emergency since their minds are somewhere else.  What if this was your operating room team?  Something can and at some point will go wrong.

So, back in the OR the music is on and everything is rocking.  The patient is a middle aged guy with his abdomen open having a colon tumor removed.  He did OK after the procedure and went home but kept complaining of a belly ache.  Finally an X-ray was taken (yes it’s real but no names, dates or places please).  The X-ray showed a 13-inch long, two-inch wide surgical retractor, known as a “ribbon retractor”, a stainless steel retractor resembling a metal ruler was inside the patient.  Come on, how can you leave something over a foot long inside someone and not know it?

According to the findings of the hospital investigation and public court documents (yes the surgeons got sued) it had been “accidentally left in the patient after it somehow slipped from the hands of a distracted doctor during the procedure.”  It had to be surgically removed by another team of surgeons – who hopefully were paying full attention this time.

Distracted performance is a real matter of patient safety.  As good team leaders we need to enforce an environment where everyone at every position on the team is fully engaged during those critical times of the procedure.  Things that we might not find distracting can be distracting to others and degrade the performance of the entire team.  Be on guard during times when events become distracting such as phones ringing and shift and personnel changes.  Maintain your own and team “situational awareness” by continuously assessing the circumstances and testing this by communicating with your team. We can learn from others’ errors so as not to make them ourselves.  This incident isn’t from a long-gone era, it was only settled a couple of years ago.  We can and must do better at the simple task of paying attention and maintaining the “sterile environment” that is necessary for maximum performance from everyone on the team.

 

Click here to download a report from the NHTSA on distracted driving (pdf file)

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Posted in Human Factors, Patient Safety, Uncategorized.

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  1. Billy Schmidt says

    Ken: I saw a first a few weeks ago at Fire Rescue. Responded to a stabbing call. Found patient with a knife still in his belly, but it didn’t stop him from texting as we were approaching. The crew stabilized the knife and removed the phone!



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