Medical Surgical Nursing Department, College of Nursing, Taif University, Taif, Saudi Arabia.
King Salman Bin Abdulaziz Medical City, Madinah Region, Saudi Arabia.
Inquiry. 2024 Jan-Dec;61:469580241279811. doi: 10.1177/00469580241279811.
Emergency department nurses may fail to see medical items in emergency cart drawers, such as syringes and tubes, while handling emergency situations, which can often contribute to a delay in managing the case. This is a phenomenon known as Looked-but-failed-to-see (LBFTS) and occurs when the observer fails to detect a visible visual stimulus among various other stimuli. LBFTS is a group of human errors, including inattentional blindness (IB), satisfaction of search, and biased search processes, and is associated with constraints on human visual processing. LBFTS has been studied extensively in the fields of aviation, military, radiology, and road safety; however, the role of LBFTS in hospital ED has generally been overlooked. Hence, a key aim of this study was to investigate the possibility of the occurrence of LBFTS among ED nurses while searching for a particular medical item during a real-life emergency. An observational cross-sectional blinded study was conducted to determine the occurrence of LBFTS in a real-life visual search task during resuscitation cases in ED. The A-B-C (antecedent-behavior-consequence) observation and recording naturalistic observation technique was used. A total of 45 ED nurses who were assigned to either the crash cart or the intubation trolley at the time of data collection agreed to participate and were included in the analysis. The results revealed that LBFTS accounted for 66% of the cases where emergency items were brought from another location. Participants missed seeing an item, although the item was directly in front of their eyes. Factors such as the perception of cognitive workload at the time of data collection positively impacted the increase in LBFTS P = .021). Taken together, the results of the present study and recent visual studies support the occurrence of LBFTS among nurses working in ED. Devising successful strategies to reduce this phenomenon could translate directly into saved lives.
急诊科护士在处理紧急情况时，可能会忽略急救车抽屉中的医疗物品，例如注射器和管子，这往往会导致病例管理延迟。这种现象被称为“看过但没看到”（Looked-but-failed-to-see，LBFTS），当观察者未能在各种其他刺激中检测到可见的视觉刺激时就会发生。LBFTS 是一组人为错误，包括注意力不集中性盲视（inattentional blindness，IB）、搜索满足感和有偏差的搜索过程，与人类视觉处理的限制有关。LBFTS 在航空、军事、放射学和道路安全等领域已经得到了广泛的研究；然而，LBFTS 在医院急诊科的作用通常被忽视。因此，本研究的一个主要目标是调查急诊科护士在真实紧急情况下寻找特定医疗物品时发生 LBFTS 的可能性。本研究采用了观察性横断面盲法研究，以确定在急诊科复苏病例中进行真实视觉搜索任务时 LBFTS 的发生情况。使用 A-B-C（前因-行为-后果）观察和记录自然观察技术。共有 45 名急诊科护士在数据收集时被分配到急救车或插管车，他们同意参与并被纳入分析。结果显示，在从其他地方带来急救物品的病例中，有 66%的情况下出现了 LBFTS。尽管物品就在参与者的眼前，但他们还是错过了看到物品。在数据收集时感知到的认知工作量等因素会对 LBFTS 的增加产生积极影响（P=.021）。综上所述，本研究和最近的视觉研究结果支持急诊科护士中存在 LBFTS 的情况。制定成功的策略来减少这种现象可以直接转化为拯救生命。
