Distraction is Deadly

• 

  Nick Nudell , Visionary Paramedic Chief Data Officer at UCHealth EMS, The Paramedic Foundation

  5 years ago

Distraction is Deadly: Driving, Patient care, and Education

Presented by Greg Friese, MS, NRP
Director of Education and Communication
CentreLearn Solutions, LLC

Divide paper into fourths
Label each quadrant...hat tip to Steven Covey
Important and urgent
Important and not urgent
Not important and urgent
Not important and not urgent

Place these things into each quadrant
Facebook notifications – friend request, you were tagged in a post
Email about a sale at your favorite store (REI)
Text message from your spouse
Text message from your child
Phone call from friends and family
Phone call from a student
Email from a student
Email from a vendor
Email from employer
Out of office reply
Driving ambulance to cardiac arrest
Driving ambulance for dialysis patient return to home
Mild asthma
Severe asthma

Discuss urgent, important
Discuss types of calls and messages that are
Important and urgent
Important and not urgent
Not important and urgent
Not important and not urgent
(Estimate percentage of calls in each category)

Experiential activity … flip the classroom … have them teach each other

Day 1 Class 1. Students need to learn how to
Disable auditory, visual, and kinetic notifications
Disable auto refresh for social networks (Facebook, Twitter, Google+, Instagram, etc.)
Put phone out of physical and visual reach

98% of people surveyed know it is dangerous to text and drive.

74% of people do it anyway.

Survey by Center for Internet and Technology Addiction and AT&T

http://www.washingtonpost.com/blogs/dr-gridlock/wp/2014/11/06/drivers-get-a-rush-from-text-messaging/

I can’t think of much else where the gulf between knowing danger and participating in behavior is so great….
Smoke Tobacco (18% of Americans http://www.cdc.gov/tobacco/data_statistics/fact_sheets/fast_facts/)
Heroin (1.6% of Americans have used http://www.drugabuse.gov/publications/drugfacts/heroin)
Soda/Cola (48% drink on a daily basis. http://www.gallup.com/poll/156116/nearly-half-americans-drink-soda-daily.aspx)

Distraction is a Real Issue

http://www.ntsb.gov/news/2013/130409.html

http://www.ntsb.gov/news/events/2013/mosby_mo/Abstract_Mosby_MO.pdf

Pilot was sending TEXT messages …. Dozens and dozens during pre-flight. Messages sent
while flying,
while the helicopter was being prepared for return to service, and
during his telephone call to the communication specialist when making his decision to continue the mission,

There are 3 general types of distraction

Manual or mechanical distraction – hands off the wheel

Anything that takes hands off the wheel – eating, texting, tying boots, grooming, adjust radio – lights – sirens

[this guy is doing both]

Manual distraction solution…hands-free and voice to text devices are not safer.

Hands free is not better. From http://tti.tamu.edu/2013/04/23/voice-to-text-apps-offer-no-driving-safety-benefit-as-with-manual-texting-reaction-times-double/

Cognitive load is not changed

Visual distraction - eyes of the road

Something that causes you to look away from road, patient, vial, syringe, protocol … sending a text.

Example of a visual distraction

Ambulance then rear ended a truck

Serious injuries to patient

http://www.prnewswire.com/news-releases/louisiana-jury-awards-117-million-to-woman-injured-in-ambulance-accident-while-pregnant-164761026.html

http://www.fireengineering.com/articles/2014/06/judge-rules-calfire-chief-to-still-stand-trial-for-fatal-crash.html

Read-ended other vehicle, killing driver.

State settled for $15 million to daughters of the victim.

Charged with misdemeanor vehicular manslaughter

Cognitive or mental distraction – thinking of something else – mind off of driving

Brain not engaged in task of driving – we aren’t aware of time we spend cognitively distracted

Get your head in the game.

Explanation of cognitive distraction
http://www.youtube.com/watch?v=Ae-mO8OxXFA&feature=share&list=PL337F74DED367FDE7

“looking but not seeing”

“Inattention blindness

https://www.aaafoundation.org/sites/default/files/MeasuringCognitiveDistractions.pdf

“AAA Foundation challenges the notion that drivers are safe and attentive as long as their eyes are on the road and their hands are on the wheel.”

https://www.aaafoundation.org/sites/default/files/MeasuringCognitiveDistractionFS.pdf

“study provides some of the strongest evidence yet that “hands-free” doesn’t mean risk free.”

From 1953 National Safety Council Video on the importance of not being distracted.

“Inside your head is the most difficult place in the world to get privacy”

http://www.youtube.com/watch?v=D-qiQh4mrHA&list=PL337F74DED367FDE7&index=1

When you read/hear about any type of collision try to understand the type or types of distraction that were contributing or causing factors:
Manual
Visual
Cognitive

Texting … all three distraction types …. That is what makes it so dangerous.

“texting while driving is especially dangerous because it combines all three types of distractions.”
http://www.cdc.gov/features/dsDistractedDriving/

Multi-tasking … not possible.

Can’t be cognitively engaged in two simultaneous tasks.

Multitasking is a MYTH!

Online conversations – in the EMS space - about the helicopter accident had a lot of people arguing that text messaging had nothing to do with this, couldn’t be proved as the cause, etc.

Learn more in this infographic:

http://www.nsc.org/safety_road/Distracted_Driving/Pages/The-Great-Multitasking-Lie.aspx

Toggle Tasking
Multi-tasking doesn’t work
Brain chooses one or the other “Toggle Tasking”
http://www.youtube.com/watch?v=L_Kzq2x-z7Y&feature=share&list=PL337F74DED367FDE7

This is reality …

Listen to wife or read email.
Listen to a presenter or read the news
Browse Facebook newsfeed or play card game with kids

Despite your desires, wishful thinking, or ongoing attempts at multi-tasking you can’t do both effectively.

Drive or talk on telephone. Make a choice.

Activity idea – recall of information while performing task of entering data into an ePCR.

Patient care toggle tasking example … assessing patient while also navigating buttons/tabs of electronic patient care report

Cognitive challenge … looking for button to click, dropdown, text field, etc while also listening to patient and 1 to 5 other people that might be giving you more information.

You can’t do this either.

Experiential activity

Game measures how reaction time is affected by external distractions.

http://www.nytimes.com/interactive/2009/07/19/technology/20090719-driving-game.html?ref=technology

This is impossible, dangerous, and potentially fatal.

“In the moments before the derailment, Garzon received a call on his work phone from Spain's national train company Renfe, court documents show. The call was to inform Francisco Garzon, 52, of the route that he needed to take. The court said Garzon was talking to train company personnel and based on black-box data recorders, appeared to be consulting a paper document at the time of the derailment. ”

http://worldnews.nbcnews.com/_news/2013/07/30/19776780-investigators-driver-of-spanish-train-that-crashed-was-talking-on-phone

Have you ever done this?

Doing this without consequence doesn’t mean you have special skills.

It means you have had a near failure.

Near failures are strong predictors for actual failure.

91% or more of US adults own a mobile phone. (Pew Internet Research project)

In 2011 CDC research … in the last 30 days (http://www.cdc.gov/features/dsDistractedDriving/)

Almost 70% of drivers reported talking on phone regularly, fairly often, and at least once.

About 31% reported reading or sending text messages or emails regularly, fairly often, and at least once.

In 2012 from Driver Electronic Device Use in 2012. NHTSA February 2012

Percent of drivers holding ears to their phones while driving

660,000 vehicles driven per daylight moment *

Estimate 9% of vehicle drivers using phone to ear of hands-free device

21% of all crashes involve people talking on cell phones

http://www.nsc.org/safety_road/Distracted_Driving/Pages/The-Great-Multitasking-Lie.aspx

Another source, NSC video 15-25% of crashes, even while the total $ of crashes is decreasing http://www.youtube.com/watch?v=3QJ26OYVfXI&feature=share&list=PL337F74DED367FDE7

Drivers on phone – handheld or handsfree – 4x as likely to be involved in a crash

http://www.nsc.org/safety_road/Distracted_Driving/Pages/The-Great-Multitasking-Lie.aspx

Drivers on phone – in a simulator – had reaction times slower than drivers with blood alcohol content of 0.08

http://www.nsc.org/safety_road/Distracted_Driving/Pages/The-Great-Multitasking-Lie.aspx

Couple that with what we know about the impact of fatigue. 18 hours without sleep can be enough to have this equivalent BAC

From Distracted Driving and Risk of Road Crashes among Novice and Experienced Drivers
Sheila G. Klauer, Ph.D., Feng Guo, Ph.D., Bruce G. Simons-Morton, Ed.D., M.P.H., Marie Claude Ouimet, Ph.D., Suzanne E. Lee, Ph.D., and Thomas A. Dingus, Ph.D.

N Engl J Med 2013;370:54-9.

http://www.swnews4u.com/section/170/article/15514/

Grant County deputies and the Platteville Fire Department and EMS responded to this crash on U.S. 151 at Southwest Road Monday around 11:35 a.m.
The 2014 Ford Mustang owned by Avis Rent a Car and driven by Matthew Bruhn, 37, Jeffersron, rear-ended a tractor driven by Matthew Miller, 33, Platteville, pulling a trailer full of liquid manure.
The sheriff’s department said Bruhn had been talking and texting on his cellphone when he hit the trailer.
Bruhn was treated at Southwest Health Center in Platteville for a broken finger.
U.S. 151 was blocked during manure cleanup.
The state Department of Natural Resources 

Did your mom say this?

http://theactivepursuit.com/texting-driver-convicted-of-homicide-in-crash-that-killed-bicyclist/

View video “From One Second to the Next”

Documentary directed by Werner Herzog. Available on YouTube.

http://www.kbtx.com/home/headlines/Distracted-Driver-Causes-Minor-Crash-with-Ambulance--202222151.html

Ambulances hit by distracted drivers

Responders on the roadway hit by distracted drivers

http://www.wave3.com/story/26209597/fatal-accident-involving-fire-truck-semi-on-65-south

FF killed
FF injured

“Distracted driving was at least one of the factors in that deadly crash Feb. 16, 2013.  IEMS members Timothy McCormick and Cody Medley died, their ambulance was smashed into by a driver who ran a red light.”Read more: http://fox59.com/2013/02/18/fatal-accident-again-highlights-problem-of-distracted-driving/#ixzz31ieyjIT0

Connected topics
Just culture
CRM
Patient Safety

We are going to continue to dig on distraction …

Activity idea …
[From Strategy for National EMS Culture of Safety]
What is the risk of distraction during patient response, assessment, treatment, and transport?
Understanding, reducing, eliminating distraction will have an impact on all community groups.

to self, partner, community (bystanders), and patient

Self – needle stick, lifting injury

Partner – lifting, slips, and falls, scanning for cross traffic (driver licking massive ice cream cone as driving through major intersection with red lights and sirens

Patient – medication administration error

Community – vehicle collision

What is a medical error?

National Coordinating Council for Medication Error and Prevention (NCCMERP) has approved the following as its working definition of medication error:

“... any preventable event that may cause or lead to inappropriate medication use or patient harm, while the medication is in the control of the health care professional, patient, or consumer. Such events may be related to professional practice, health care products, procedures, and systems including: prescribing; order communication; product labeling, packaging and nomenclature; compounding; dispensing; distribution; administration; education; monitoring; and use”

http://amcp.org/WorkArea/DownloadAsset.aspx?id=9300

“Good person doing what they think is the right thing to do.”
Paul Misasi
Sedgewick County EMS

Listen to Part 1 http://www.emseducast.com/archives/1166
Listen to Part 2 http://www.emseducast.com/archives/1179

Medication errors aren’t the fault of an individual forgetting or not using the 5 Rights, 6 Rights, or 10 Golden Rules of Medication administration

And the prominent Institute of
Medicine report To Err Is Human: Building a Safer Healthcare System notes:
“The majority of medical errors do not result from individual recklessness or the actions of a particular group—this is not a ‘bad apple’ problem. More commonly, errors are caused by faulty systems, processes, and conditions that lead people to make mistakes or fail to prevent them.”26

Draw up and administer ….

What are distractions and disruptions that happen when you are asked to administer medications … list several.

Back of the ambulance can become many of these things …

Med room had plenty of opportunities for visual, manual, and cognitive distraction.

But also lots of chances for disruption and interruption.

Share my experience with the Emergency Department “Med Room” was also …
Shared by urgent care staff and supplies
Storage area for lots of other supplies
Buffet and eating area for staff
Gathering spot for informal conversation
Communication and sign-ups

Lecture 1 System Analysis Slide – in a discussion of 10 key elements of the medication system from the Learning Aids: Medication Errors, 2nd Edition
From the American Pharmacists Association
http://www.pharmacist.com/learning-aids-medication-errors-2nd-edition

Keep in mind that is mostly aimed at pharmacists, nurses, etc.

There are a lot of things that contribute to distraction …

Fatigue
Stress
Hunger
Environment
Culture – how we act in workspace

Culture … how we act in the workspace

NAME of Partner… Please put down the phone and focus on driving.

Our patient is expecting us to arrive ready and able to care for their emergency.

My kids are counting on me getting home safely at the end of this shift.

To meet their expectations I need your help.

I also promise that I will do everything I can to make sure you get home safely from this shift.

Experiential activity …
That is the script I use to call out distraction that puts me at risk.

We should all have scripts that …
Label the distraction
Remind of the consequences
Ask for a behavior change
Promise a willing partner

Plan and deliver an injury prevention program … Distracted Driving

Learning facts about distracted may change student’s attitudes (about risk) and behavior (texting).

Deliver to different audiences … teens, civic groups, professional drivers

Injury Prevention – poster – develop and distribute.

Utilize other campaigns and distribute with other student groups in college

Decreasing Disruptions Reduces Error http://www.nursezone.com/Nursing-News-Events/more-news.aspx?ID=18693

Disruptions and interruptions… take lots of forms …

Disruptive student behaviors (see Rom’s presentation on dealing with difficult student behaviors)
Activities outside of or adjacent to classroom
Novel situation – dog in the classroom
Something more desirable … pizza delivery next store.
Another person in the ambulance

Observation of behavior

Count interruptions for different tasks

Times kids interrupt conversation between me an my wife :)

http://www.marylandpatientsafety.org/html/education/solutions/2010/documents/communication/Medication_Interruptions_and_Distractions.pdf
Distraction – diverts attention
Interruption – causes stop and restart

From http://www.grhosp.on.ca/epulseaugust2012

“While managing the care for high volumes of patients, staff on the bustling unit identified that nursing staff dealt with multiple interactions at the same time as they’re entering medication orders or getting medication ready for patients.
Staff analyzed total medication errors over a three month period on the surgical inpatient unit. The study revealed that up to a third of the mistakes were linked to distractions from avoidable interruptions.
Staff members have created a “No Interruption” policy, that uses signs and special uniforms to identify areas in which staff are not to be interrupted while doing certain work.”


Grand River Hospital has implemented http://www.grhosp.on.ca/epulseaugust2012

Signs
Special uniforms

To notify other staff to not interrupt nurses preparing and administering medications.

Preventing disruptions and interruptions

We could adapt the sign for paramedics.

Hang on the window of the ambulance … use in the lab.

Limit the number of people that can be in the ambulance or inside the no interruption zone

The following Patient Safety event was entered into the EVENT system today, August 1, 2013, at 5:28pm CDT. The record may have been altered to remove identifiers or for other administrative purposes.

Description: Close-Call.  While preparing two medications for patient administration, the medic preparing them started drawing one from a vial of Adenocard, 6 mg/2 mL when they intended to prepare Zofran, 4 mg/2 mL.  The other medic caught the mistake while it was being withdrawn from vial.   No patient harm.
Cause: Crew reviewed and believes that the primary contributor was multiple distractions from too many 1st responders & their wanting to converse while medic was working on preparing multiple syringes.  Both correct med. syringes were then properly labeled & medication check procedures completed before administration.  Confused vials were also the same physical size.


No Interruptions Please: Impact of a No Interruption Zone on Medication Safety in Intensive Care Units
http://ccn.aacnjournals.org/content/30/3/21.short

No Interruption Zone
Where?
How to identify?
When?

What would you put in the no interruption zone?
Paramedic doing drug calculations
Cardiac arrest pit crew.

Other ideas
Side tracks on the safety express. Interruptions lead to errors and unfinished… Wait, what was I doing?
http://www.ismp.org/newsletters/acutecare/showarticle.asp?id=37

Put the code team in the no interruption zone …

From Johnson County Med Act
Cardiac Arrest Check List and Pit Crew Procedure

How do you stay on the road or after an interruption … how do you get back on track?

Ask the class for ideas …

In the classroom as an instructor

In the classroom as a student

In the ambulance as a paramedic or a paramedic preceptor

Checklists …

From Johnson County Med Act
Cardiac Arrest Check List and Pit Crew Procedure

Job Aids and Processes help get you back on track, as well as signaling a no interruption zone – time and place.

Conversations that are scripted/organized need to be practiced and consistently used.

http://www.kagoon.com/journal-of-emergency-primary-health-care-jephc-vol-7-issue-3-2009-article-990374/main
“The  crosschecking‟ measure  is  also  viewed  by  Jenson  et  al  as  the  most  effective  single  measure to  reduce medication error.”

What are the opportunities in class to add in “read backs”
Homework assignments
Quiz/test instructions
Scenarios
Skill sessions

Sedgwick County EMS
Medication Administration Cross-Check© User Manual

Draw attention to …
Poor communication
Interruptions
Preoccupation
Task Saturation

Innovative approaches to reducing nurses' distractions during medication administration.
http://www.ncbi.nlm.nih.gov/pubmed/16022030

Being clear on when and how devices can be used can help students stay on track

Cue students of important information … before giving the important instructions

Assignment instructions
Test instructions
Other critical information

http://www.everyonegoeshome.com/seatbelts/
International First Responder Seatbelt Pledge

Often have associated education activities

http://www.everyonegoeshome.com/seatbelts/
International First Responder Seatbelt Pledge

Reviewing and taking pledge could be a class activity

No texting and driving pledges

ItCanWait.com
http://www.itcanwait.com/?WT.srch=1&wtPaidSearchTerm=don%27t+text+and+drive+pledge

NoPhoneZonePledge.com
http://nophonezonepledge.org/

Focus Driven – advocates for cell-free driving
http://www.focusdriven.org/

Digital Paramedic – Distraction Triage

Job Action Sheet
Essential Responsibilities
Silence phone
Turn off notifications
Reduce inputs
Prioritize incoming transmissions – with rules and filters

TeXTe - Emergency SMS
Anyone with the “code” word can get a text message to you … even when phone is on silent.

https://play.google.com/store/apps/details?id=ravid.dev.esms

Engineering Controls

… app … needs to be turned on
AT&T Driver Mode
https://play.google.com/store/apps/details?id=com.drivemode

Stop receiving emails

Look for “Unsubscribe” in the fine print.

Experiential activity … focus time, time on task, time tracking

App or stop watch or egg timer or phone or Google search (set timer 2 minutes)

… progressively lengthen time you stay focused.

But also acknowledge we can’t maintain heightened awareness/attentiveness for an unlimited period of time.

Time to be able to check a pulse, count breaths, listen to heart sounds, listen to lung sounds

Dispatch info, size-up, giving an assignment

Collect a SAMPLE history, perform a head to toe exam, start an IV, review a protocol and calculate a medical dosage

Connecting to a hydrant and flowing water

Set-up hydraulic tools

Don Level A or B HazMat PPE

Read a book chapter

Research and write a portion of a presentation

Listen to a lecture

Confrontation of distraction starts with looking at our own behaviors … from a March 2010 article in New York Times. Part of a prize winning series of articles on “Driven to Distraction”

New York Times, March 2010
http://www.nytimes.com/2010/03/11/technology/11distracted.html?pagewanted=all

Article raises issue of state laws that ban texting while driving but exempt emergency responders

Ohio texting ban…http://bmv.ohio.gov/texting_ban.stm


Sec. 4511.204.  (A) No person shall drive a motor vehicle, trackless trolley, or streetcar on any street, highway, or property open to the public for vehicular traffic while using a handheld electronic wireless communications device to write, send, or read a text-based communication.
(B) Division (A) of this section does not apply to any of the following:
(1) A person using a handheld electronic wireless communications device in that manner for emergency purposes, including an emergency contact with a law enforcement agency, hospital or health care provider, fire department, or other similar emergency agency or entity;
(2) A person driving a public safety vehicle who uses a handheld electronic wireless communications device in that manner in the course of the person's duties;
(3) A person using a handheld electronic wireless communications device in that manner whose motor vehicle is in a stationary position and who is outside a lane of travel;
(4) A person reading, selecting, or entering a name or telephone number in a handheld electronic wireless communications device for the purpose of making or receiving a telephone call;
(5) A person receiving wireless messages on a device regarding the operation or navigation of a motor vehicle; safety-related information, including emergency, traffic, or weather alerts; or data used primarily by the motor vehicle;
(6) A person receiving wireless messages via radio waves;
(7) A person using a device for navigation purposes;
(8) A person conducting wireless interpersonal communication with a device that does not require manually entering letters, numbers, or symbols or reading text messages, except to activate, deactivate, or initiate the device or a feature or function of the device;
(9) A person operating a commercial truck while using a mobile data terminal that transmits and receives data;
(10) A person using a handheld electronic wireless communications device in conjunction with a voice-operated or hands-free device feature or function of the vehicle.

“VFIS wants you to know the facts when it comes to distracted driving while operating an emergency service vehicle.”

View, download, or embed full infographic at http://www.vfis.com/free-infographic-firefighter-EMS-distracted-driving.htm

Last sentence of chapter 1 of People Care, 2nd edition by Thom Dick.