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PATIENT SAFETY

Interruptions and Blood Transfusion Checks: Lessons from the Simulated Operating Room

David Liu, BEng(Hons)^*, Tobias Grundgeiger, DiplPsych, Penelope M. Sanderson, PhD, FASSA^*, Simon A. Jenkins, BMBS, FANZCA, and Terrence A. Leane, RN, GDPH GDNursSci

From the *School of Information Technology and Electrical Engineering, The University of Queensland, St Lucia, Queensland, Australia; School of Psychology, The University of Queensland, St Lucia, Queensland, Australia; School of Medicine, The University of Queensland, St Lucia, Queensland, Australia; and Department of Anesthesia and Intensive Care, Royal Adelaide Hospital, Adelaide, Australia.

Address correspondence to David Liu, School of Information Technology and Electrical Engineering, The University of Queensland, St Lucia, QLD 4072, Australia. Address e-mail to naskies{at}acm.org.

Abstract

Interruptions occur frequently in the operating room with both positive and negative consequences. Interruptions can distract anesthesiologists from safety-critical tasks, such as the pretransfusion blood check. In a simulated operating room, 12 anesthesiologists requested blood as part of a "bleeding patient" scenario. They were distracted while their assistant accepted delivery of the product and began transfusing without performing the standard check. Anesthesiologists who immediately engaged with the interruption failed to notice the omission, whereas those who rejected or deferred the interruption all noted and remedied the omitted check (P < 0.05). We discuss the role of displays and strategies on safety.

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