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Cell phones are great. They have made great improvements, not only in our private lives, but also in healthcare. They allow us to get medical information to our fingertips almost instantaneously. They allow us to get appropriate access to necessary medical records easily. They give us access to medical algorithms and calculators at the point of care. They have largely made the pager an anachronism. The ability to do asynchronous communication (for example, by texting or email) has made communication more efficient. We now even use them to alert appropriate caregivers to alarms and alerts, helping to reduce alarm fatigue (keeping in mind the potential downside that we discussed in our February 9, 2016 Patient Safety Tip of the Week “It was just a matter of time…”).
But not everything about cell phones in healthcare is rosy. They can serve as a significant and growing source of distractions and interruptions in multiple healthcare venues, such as the OR (see our multiple columns listed below).
But it’s not just in the OR that they may be a source of distraction. A new study in a Pediatric Intensive Care Unit (PICU) setting (Bonafide 2019) demonstrated that incoming telephone call interruptions may be temporally associated with medication administration errors among PICU nurses.
This was a retrospective study looking at incoming telephone calls and text messages received on the institutional mobile telephone assigned to the nurse in the 10 minutes leading up to a medication administration attempt. Medication errors included both reported medication administration errors and bar code medication administration error alerts generated when nurses attempted to give medications without active orders for the patient whose bar code they scanned.
The overall rate of errors during 238,540 medication administration attempts was 3.1% when nurses were uninterrupted by incoming telephone calls and 3.7% when they were interrupted by such calls.
Risk of error did vary by shift, nurse level of experience, nurse to patient ratio, and level of patient care required. Phone call related errors were more frequent on the night shift and for nurses with less than 6 months of experience. Nurses administering medications to 1 or more patients receiving mechanical ventilation and arterial catheterization while caring for at least 1 other patient also had an increased risk of error related to phone calls.
Interestingly, incoming text messages were not associated with error.
There is one consideration we always raise with a study like this. The study did not measure the impact on overall errors in the PICU. It focused solely on those related to medication errors. It is quite likely that many of the phone calls may have been important in averting adverse events for other patients in the PICU.
Answers are not readily available to address this issue. Obviously, if we truly make medication administration a “no interruption zone”, the answer is for the nurse to turn off the cell phone all together. That might be a solution on a floor where one nurse is charged with medication administration. However, in a unit like the PICU the nurse is likely administering medications to just the one or two patients he/she is responsible for. It may not be practical to turn off cell phones in that scenario (particularly if their cell phones are tied to an alarm/alert system). Even on the floor, it might be impractical on some shifts for a nurse administering medications to be totally freed from other responsibilities that might necessitate use of a cell phone.
The issue of personal phones in other venues, particularly the OR, has long been debated. A case described in our August 20, 2019 Patient Safety Tip of the Week “Yet Another (Not So) Unusual RSI” was a great example of a reason we counsel against allowing phones in the OR. In that case, a surgeon’s phone ringing several times during a surgical count was one of several factors likely contributing to a retained surgical item. Our Patient Safety Tips of the Week May 21, 2013 “Perioperative Distractions”, March 17, 2015 “Distractions in the OR”, and July 21, 2015 “Avoiding Distractions in the OR” had detailed discussion about use of cell phones and other wireless devices in and around the OR with multiple examples of distractions related to such in the OR. There are a multitude of issues related to cell phones in the OR including not only interruptions and distractions but also infection control issues, security and confidentiality issues, and detrimental effects on communication in the OR. Our own recommendation is for all the OR team to leave their cellphones at the main OR desk where someone can triage incoming phone calls and messages.
AORN (Association of periOperative Registered Nurses) recently proposed several recommendations to reduce distractions and interruptions in the OR (AORN 2019). Some focused on reducing overall sources of noise pollution in the OR. But others focused specifically on cell phones.
One recommendation is to “Emphasize the importance of limiting non-essential conversations, muting cell phones or limiting their use, and limiting the number of people in the OR.”
Another is to reiterate safe cell phone use, recognizing that some facilities allow surgical team members to carry their personal cell phone with them, Regular reminders about safe cell phone use can be helpful, such as “Personal devices may add to the overall noise pollution in the OR, which can distract personnel from clear communication and safe patient care.” It goes on to emphasize minimization of distractions during critical phases of the procedure, such as the time out, anesthesia induction and emergence, surgical counts, and specimen management. Especially during those critical times, “personal devices should be left outside the OR, turned off, placed on vibrate or silent mode, and handled only when needed.”
A number of questions about cell phones in the OR were addressed in a recent AORN Journal (Ogg 2019). The AORN "Guideline for a safe environment of care" recommends that personal electronic devices should be limited to use directly required for job performance. It states that health care organizations should have policies and procedures in place that specify when a cell phone may be brought into the OR. Furthermore, it states that perioperative personnel also should consider interventions to mitigate the known risks associated with bringing personal electronic devices into the OR.
They note the risks involved with bringing a personal electronic device into the OR include:
They cite statistics on microbial contamination of cell phones and note interventions that may reduce the risk of a surgical site infection (SSI) originating from contaminated personal electronic devices include cleaning the device regularly, handling the device sparingly, and performing hand hygiene after each use.
And the other issue related to cell phones is the issue of texting. Orders should never be texted (see our multiple columns on the subject below). But even for messages used for communication other than orders, care must be taken so that commonly used text abbreviations and shortcuts are not mistaken by these receiving the texts.
Prior Patient Safety Tips of the Week dealing with cell phones:
See our other Patient Safety Tip of the Week columns dealing with texting:
Bonafide CP, Miller JM, Localio AR, et al. Association Between Mobile Telephone Interruptions and Medication Administration Errors in a Pediatric Intensive Care Unit. JAMA Pediatr 2019; Published online December 20, 2019
AORN (Association of periOperative Registered Nurses). Can You Hear Me? 3 Reminders to Reduce OR Distractions. Periop Today 2019; December 11, 2019
Ogg MJ, Anderson MA. Clinical Issues—August 2019. AORN Journal 2019; 110(2): 199-202 First published: 29 July 2019
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