Jones Angela, Johnstone Megan-Jane
Deakin University, School of Nursing and Midwifery, Locked Bag 20000, Geelong, 3220 Victoria, Australia.
Aust Crit Care. 2017 Jul;30(4):219-223. doi: 10.1016/j.aucc.2016.09.005. Epub 2016 Oct 5.
Failure to identify and respond to clinical deterioration is an important measure of patient safety, hospital performance and quality of care. Although studies have identified the role of patient, system and human factors in failure to rescue events, the role of 'inattentional blindness' as a possible contributing factor has been overlooked.
To explore the nature and possible patient safety implications of inattentional blindness in critical care, emergency and perioperative nursing contexts.
Analysis of four case scenarios drawn from a naturalistic inquiry investigating how nurses identify and manage gaps (discontinuities) in care. Data were collected via in-depth interviews from a purposeful sample of 71 nurses, of which 20 were critical care nurses, 19 were emergency nurses and 16 were perioperative nurses. Case scenarios were identified, selected and analysed using inattentional blindness as an interpretive frame.
The four case scenarios presented here suggest that failures to recognise and act upon patient observations suggestive of clinical deterioration could be explained by inattentional blindness. In all but one of the cases reported, vital signs were measured and recorded on a regular basis. However, teams of nurses and doctors failed to 'see' the early signs of clinical deterioration. The high-stress, high-complexity nature of the clinical settings in which these cases occurred coupled with high cognitive workload, noise and frequent interruptions create the conditions for inattentional blindness.
The case scenarios considered in this report raise the possibility that inattentional blindness is a salient but overlooked human factor in failure to rescue events across the critical care spectrum. Further comparative cross-disciplinary research is warranted to enable a better understanding of the nature and possible patient safety implications of inattentional blindness in critical care nursing contexts.
未能识别并应对临床病情恶化是衡量患者安全、医院绩效和护理质量的一项重要指标。尽管已有研究确定了患者、系统和人为因素在未能成功抢救事件中的作用，但“无意视盲”作为一个可能的促成因素的作用却被忽视了。
探讨重症监护、急诊和围手术期护理环境中无意视盲的本质及其对患者安全可能产生的影响。
对四个案例进行分析，这些案例来自一项自然主义调查，该调查旨在研究护士如何识别和处理护理中的差距（不连续性）。通过对71名护士进行有目的抽样的深入访谈收集数据，其中20名是重症监护护士，19名是急诊护士，16名是围手术期护士。以无意视盲作为解释框架来识别、选择和分析案例。
这里呈现的四个案例表明，未能识别患者提示临床病情恶化的观察结果并采取相应行动，可能是由无意视盲导致的。在报告的除一个案例之外的所有案例中，生命体征都定期进行了测量和记录。然而，护士和医生团队未能“察觉”临床病情恶化的早期迹象。这些案例发生的临床环境具有高压力、高复杂性，再加上认知工作量大、噪音干扰和频繁中断，为无意视盲创造了条件。
本报告中考虑的案例表明，无意视盲可能是重症监护领域未能成功抢救事件中一个显著但被忽视的人为因素。有必要开展进一步的跨学科比较研究，以便更好地理解重症监护护理环境中无意视盲的本质及其对患者安全可能产生的影响。
