在重症监护、急诊及围手术期情境下,非注意盲视与病情恶化患者的抢救失败:4例病案报告

Inattentional blindness and failures to rescue the deteriorating patient in critical care,emergency and perioperative settings:four case scenarios

背景:对临床恶化的识别和应对失败,是考核患者安全、医院绩效和护理质量的重要标准。虽然已有研究明确了患者、医院系统和人为因素在抢救失败的病案中的作用,但作为一个可能的影响因素,非注意盲视的作用被忽视了。目的:在重症护理、急诊和围手术期护理情境下,探讨非注意盲视的特性和对患者安全的影响。方法:从自然调研中选择了4例病案,分析护士如何识别和管理护理间隙(不连续性)。通过深入访谈采集数据,访谈的目标样本为71名护士,其中20名为重症护理护士,19名为急诊护士,16名为围手术期护士。以非注意盲视的角度,完成病案的鉴别、选择和分析。结果 :本文报告的4例病案提示,当患者的观测指标已提示临床恶化时,未能识别和处理,这可以用非注意盲视来解释。对本文报道的全部病案(1例除外),所有生命体征都进行了定期测量和记录。但是,医护团队未能"看到"临床恶化的早期征象。这些病案发生的临床环境极具压力和复杂性,伴随着高认知工作负荷、噪音和频繁干扰,为非注意盲视创造了条件。结论 :本报告涉及的病案提出了在危重医疗范围内,对抢救失败的病例来说,非注意盲视是一个突出的但被忽视的人为因素的可能性。进一步的学科交叉比较研究,可以确保更好地理解非注意盲视在重症监护情境下的特性及其对患者安全的可能的影响。

Background： 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. Objective： To explore the nature and possible patient safety implications ofinattentional blindness in critical care, emergency and perioperative nursing contexts. Methods： 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. Results： 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. Conclusion： 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 ofinattentional blindness in critical care nursing contexts.