Medscape "Article" on Inattentional Blindness (about med errors)

[DolceVita, ADN, BSN, RN]

I thought this was an interesting article introducing the concept of inattentional blindness. I did notice that no doctors are making any errors in the examples (see the full article to get what I mean).

From the site Medscape Med Students published by ISMP Medication Safety Alert!® Acute Care Edition June 15, 2009.

The link is:

http://www.medscape.com/viewarticle/703889?src=mp&spon=25&uac=126790AG

The full article can be read at the above link. It is free to sign up for the site and it has some interesting articles.

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Inattentional Blindness: What Captures Your Attention?

"A nurse pulls a vial of heparin from an automated dispensing cabinet (ADC). She reads the label, prepares the medication, and administers it intravenously to an infant. The infant receives heparin in a concentration of 10,000 units/mL instead of 10 units/mL and dies.

A pharmacist enters a prescription for methotrexate daily into the pharmacy computer. A dose warning appears on the screen. The pharmacist reads the warning, bypasses it, and dispenses the medication as entered. The patient receives an overdose of the medication and dies."

It continuous:

"How do we process information?

Most mental processing occurs outside of conscious awareness. The amount of information that can be taken in by our senses is limitless. But the brain has very limited resources when it comes to attentiveness. Our senses receive much more information than can possibly be processed at one time. To combat information overload, the brain allows large amounts of information through almost entirely unassimilated, peeling off just a few pieces of selected information for a closer look.[2]

In deciding what to focus on, the brain scans about 30-40 pieces of information (e.g., sights, sounds, smells, tactile information) per second, until something captures its attention.[2] Our attention filter selects just a small amount of information to process, and anything leftover gets short shrift. The rest of the information never reaches our consciousness--thus the term inattentional blindness. Unfortunately, the brain is a master at filling in the gaps and compiling an integrated portrait of reality based on just a flickering view.[1]

Accidents happen when attention mistakenly filters away important information and the brain fills in the gaps with what is aptly referred to as a "grand illusion."[2] Thus, in the examples above, the brains of the individuals involved in the errors filtered out important information on medication labels and computer screens, and filled in the gaps with erroneous information that led them to believe they had the correct medication or had read the warning appropriately."

[DolceVita, ADN, BSN, RN]

For copyright reasons only a very small portion of this article is posted.

[llg, PhD, RN]

Thanks for posting this. It is a good reference for me to use on a pet project on a related topic.

[nursej22, MSN, RN]

In my experience, doctors (other than anesthesia) rarely administer medications. If they make an ordering error, it gets caught, hopefully, by the pharmacist and/or nurse. Like the saying goes: "**** rolls downhill". If we don't catch their mistake and give a wrong drug or dose, then we make the error.

I keep hoping for the day when I can pass meds without constant interruptions. IMO, that, more than anything (fancy labels, PYXIS, bar-codes, 2 pt. identifiers) would cut down on med errors.

[DolceVita, ADN, BSN, RN]

In my experience, doctors (other than anesthesia) rarely administer medications. If they make an ordering error, it gets caught, hopefully, by the pharmacist and/or nurse. Like the saying goes: "**** rolls downhill". If we don't catch their mistake and give a wrong drug or dose, then we make the error.

I keep hoping for the day when I can pass meds without constant interruptions. IMO, that, more than anything (fancy labels, PYXIS, bar-codes, 2 pt. identifiers) would cut down on med errors.

Yes I thought of that too. Still, it isn't only medication errors that can be made, right?

I know I am just a student but it does seem that nurses are where the buck stops.