Failure to perceive clinical events: An under-recognised source of error

Greig, Paul; Higham, Helen; Nobre, Anna C.

doi:10.1016/j.resuscitation.2014.03.316

Cited by 35 publications

(23 citation statements)

References 21 publications

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“…Increased workload is associated with stress, perception errors and consequently impaired decisionmaking, all jeopardizing patient safety [1-6, 31, 35]. In this context, researchers identified inattentional blindness as a common form of perception error, which affects change detection and detection of unexpected events [9][10][11][12][13][14]41].…”

Section: Discussionmentioning

confidence: 99%

“…Although monitors are a vital source of information, observational studies have found that anesthetists look at monitors in 1-to 2-s glances and overall only during about 5% of the observed time [7,8]. It has also been found that increasing the amount of information shown on monitors reduces the ability to detect unexpected changes even when a visual event or change is in plain view [9][10][11]. This phenomenon is called inattentional blindness and is a major cause of situation awareness failure [12][13][14].…”

Section: Introductionmentioning

confidence: 99%

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Avatar-based versus conventional vital sign display in a central monitor for monitoring multiple patients: a multicenter computer-based laboratory study

Garot

Rössler

Pfarr

et al. 2020

BMC Med Inform Decis Mak

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Background: Maintaining adequate situation awareness is crucial for patient safety. Previous studies found that the use of avatar-based monitoring (Visual Patient Technology) improved the perception of vital signs compared to conventional monitoring showing numerical and waveform data; and was further associated with a reduction of perceived workload. In this study, we aimed to evaluate the effectiveness of Visual Patient Technology on perceptive performance and perceived workload when monitoring multiple patients at the same time, such as in central station monitors in intensive care units or operating rooms. Methods: A prospective, within-subject, computer-based laboratory study was performed in two tertiary care hospitals in Switzerland in 2018. Thirty-eight physician and nurse anesthetists volunteered for the study. The participants were shown four different central monitor scenarios in sequence, where each scenario displayed two critical and four healthy patients simultaneously for 10 or 30 s. After each scenario, participants had to recall the vital signs of the critical patients. Perceived workload was assessed with the National Aeronautics and Space Administration Task-Load-Index (NASA TLX) questionnaire. Results: In the 10-s scenarios, the median number of remembered vital signs significantly improved from 7 to 11 using avatar-based versus conventional monitoring with a mean of differences of 4 vital signs, 95% confidence interval (CI) 2 to 6, p < 0.001. At the same time, the median NASA TLX scores were significantly lower for avatarbased monitoring (67 vs. 77) with a mean of differences of 6 points, 95% CI 0.5 to 11, p = 0.034. In the 30-s scenarios, vital sign perception and workload did not differ significantly. Conclusions: In central monitor multiple patient monitoring, we found a significant improvement of vital sign perception and reduction of perceived workload using Visual Patient Technology, compared to conventional monitoring. The technology enabled improved assessment of patient status and may, thereby, help to increase situation awareness and enhance patient safety.

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Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Avatar-based versus conventional vital sign display in a central monitor for monitoring multiple patients: a multicenter computer-based laboratory study

Garot

Rössler

Pfarr

et al. 2020

BMC Med Inform Decis Mak

View full text Add to dashboard Cite

show abstract

“…Increased workload is associated with stress, perception errors and consequently impaired decision-making, all jeopardizing patient safety [1][2][3][4][5][6]31,35]. In this context, researchers identified inattentional blindness as a common form of perception error, which affects change detection and detection of unexpected events [9][10][11][12][13][14]42].…”

Section: Discussionmentioning

confidence: 99%

“…[3][4][5][6] Although monitors are a vital source of information, observational studies have found that anesthetists look at monitors in 1-to 2-second glances and overall only during about 5% of the observed time. [7,8] It has also been found that increasing the amount of information shown on monitors reduces the ability to detect unexpected changes even when a visual event or change is in plain view [9][10][11]. This phenomenon is called inattentional blindness and is a major cause of situation awareness failure [12][13][14].…”

Section: Introductionmentioning

confidence: 99%

Avatar-based versus conventional vital sign display in a central monitor for monitoring multiple patients: A multicenter computer-based laboratory study.

Garot¹

2019

Preprint

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Background Maintaining adequate situation awareness is crucial for patient safety. Previous studies found that the use of avatar-based monitoring (Visual Patient Technology) improved the perception of vital signs compared to conventional monitoring showing numerical and waveform data; and was further associated with a reduction of perceived workload. In this study, we aimed to evaluate the effectiveness of Visual Patient Technology on perceptive performance and perceived workload when monitoring multiple patients at the same time, such as in central station monitors in intensive care units or operating rooms. Methods A prospective, within-subject, computer-based laboratory study was performed in two tertiary care hospitals in Switzerland in 2018. Thirty-eight physician and nurse anesthetists volunteered for the study. The participants were shown four different central monitor scenarios in sequence, where each scenario displayed two critical and four healthy patients simultaneously for 10 or 30 seconds. After each scenario, participants had to recall the vital signs of the critical patients. Perceived workload was assessed with the National Aeronautics and Space Administration Task-Load-Index (NASA TLX) questionnaire. Results In the 10-second scenarios, the median number of remembered vital signs significantly improved from 7 to 11 using avatar-based versus conventional monitoring with a mean of differences of 4 vital signs, 95% confidence interval (CI) 2 to 6, p < 0.001. At the same time, the median NASA TLX scores were significantly lower for avatar-based monitoring (67 vs. 77) with a mean of differences of 6 points, 95% CI 0.5 to 11, p = 0.034. In the 30-second scenarios, vital sign perception and workload did not differ significantly. Conclusions In central monitor multiple patient monitoring, we found a significant improvement of vital sign perception and reduction of perceived workload using Visual Patient Technology, compared to conventional monitoring. The technology enabled improved assessment of patient status and may, thereby, help to increase situation awareness and enhance patient safety.

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“…Inattentional blindness and related errors of perception can contribute to adverse events in clinical practice. 2 Drew and colleagues 3 demonstrated that when 24 radiologists were required to perform a familiar lung nodule detection task, the insertion of an over-sized image of a gorilla within one of the cases was not detected by 83% of radiologists. Importantly, eye-tracking data revealed that the majority of those who erred had gazed at the gorilla, indicating a lack of association between tracking performance and the likelihood of reporting unexpected objects.…”

mentioning

confidence: 99%