Original Article

Distracted Practice and Patient Safety:

The Healthcare Team Experience
Lynn K. D’Esmond, PhD, MSHA, RN
Lynn K. D’Esmond, PhD, MSHA, RN, is Assistant Professor, University of Massachusetts Dartmouth, College of Nursing,
North Dartmouth, MA

Keywords PROBLEM. Distracted practice is the result of individuals interacting with

Cognitive resources, distraction, the environment and technology in the performance of their jobs. The
error, patient safety, situation resultant behaviors can lead to error and affect patient safety.
awareness METHODS. A qualitative descriptive approach was used that integrated
observations with semistructured interviews. The conceptual framework
Correspondence was based on the distracted driving model.
Lynn K. D’Esmond, 79 Blue Spruce FINDINGS. There were 22 observation sessions and 32 interviews
Way, Mashpee, MA 02649 (12 RNs, 11 MDs, and 9 pharmacists) completed. Results suggested that
E-mail: lynnknappdesmond@gmail. distracted practice is based on the main theme of cognitive resources,
com which varies by the subthemes of individual differences, environmental
disruptions, team awareness, and “rush mode”/time pressure.
CONCLUSIONS. Distracted practice is an individual human experience
that occurs when there are not enough cognitive resources available to
effectively complete the task at hand. In that moment an individual shifts
from thinking critically, being able to complete their current task without
error, to not thinking critically and working in an automatic mode. This
is when errors occur. Understanding the role of distracted practice is
essential for reducing errors and improving the quality of care. Additional
research is needed to evaluate intervention strategies to reduce distracted
practice.

Introduction Medicine report: To Err is Human: Building a Safer

Health Care System (Kohn, Corrigan, & Donaldson,
Distracted practice is a growing concern for 2000). Eighty percent of medical errors are attributed
healthcare professionals working in today’s complex, to human factors that include distractions (Pape, 2003;
technology saturated, acute care setting. Distracted Sitterding, Broome, Everett, & Ebright, 2012).
practice is the result of individuals interacting with Distractions are detrimental to human functioning
the environment and technology in the performance in circumstances requiring cognitive processing of
of their jobs. The resultant behaviors can lead to error large amounts of intricate, constantly changing
and affect patient safety. Researchers have found information (Feils, 2013) that occur frequently
preventable medical errors to be as high as 400,000 in healthcare settings (Biron, Lavoie-Tremblay, &
deaths per year (James, 2013). This number is four Loiselle, 2009; Feils, 2013; Ross, 2013). When new
times higher than the original estimate of 98,000 information is presented, the mind of the healthcare
deaths per year made in 2000 in the Institute of professional must be able to focus attention to properly

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Distracted Practice and Patient Safety: The Healthcare Team Experience L. K. D’Esmond

encode the information to memory for retrieval at Staff meetings were conducted on each of the
another time (Feils, 2013). Diverting focus at key observation units to explain the study and answer
times of information coding is linked to healthcare any questions. Information sheets were provided for
errors (Feils, 2013). Distracted practice is a significant staff and patients/families including frequently asked
contributing factor for healthcare errors and according questions. Informed consent was used for all interview
to James (2013) should be considered the third leading participants.
cause of death in the United States, immediately
following heart disease and cancer. A recent concept
Framework
analysis defined distracted practice as the diversion of
a portion of available cognitive resources that may be
A preliminary framework (Figure 1) for the study
needed to effectively perform/carry out the current
of distracted practice in healthcare was developed
practice activity (D’Esmond, 2015).
based on a concept analysis of distracted practice
The purpose of this study was to explore the
(D’Esmond, 2015) combined with the distracted
experience of distracted practice across the healthcare
driving model used with permission from David
team that included nurses, physicians, and pharmacists
Lee Strayer (Strayer et al., 2013). Distracted driving
in the acute care setting.
researchers have found that as the level of attention
The specific aims of this study were to:
being diverted from driving increased so did the risk
1. Describe the characteristics of distracted practice in of crashing. This preliminary framework suggests that
the acute care setting. distracted practice in healthcare is also affected by
2. Describe the context, antecedents, stimuli, and the available cognitive resources a person needs to
consequences surrounding distracted practice. carry out a task or activity and influences patient
3. Develop a preliminary model to advance the study safety. Cognitive resources are defined as the mental
of distracted practice as it relates to patient safety in space used for conscious intellectual activities (such
the acute care setting. as thinking, understanding, reasoning, remembering)
that one needs and uses to accomplish tasks. The
Methods cognitive workload required to effectively carry out
a task will determine the demand from the available
Study Design cognitive resources. Cognitive workload is the amount
of conscious mental activities needed to be performed
All procedures were approved by the Institutional or capable of being performed usually within a specific
Review Board where the study was conducted. For time period.
this study, I used a qualitative descriptive approach A semistructured interview guide was then
to describe the experience of distracted practice by developed based on an expanded framework
healthcare team members in the acute care setting. that included the antecedents, attributes, and
A combination of observations and semistructured consequences and used for each of the participant
interviews was used (Creswell, 2007). interviews (Figure 2).

Figure 1. Distracted Practice in Healthcare

Available Mental resources remaining after current

Cognitive physical and emotional factors are considered
Resources

Cognitive Mental resources required to effectively perform a task

Workload

Cognitive Diversion of some available mental

Distraction resources from current practice activity

Increased Impaired attention to

Error practice from limited
Risk cognitive resources

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L. K. D’Esmond Distracted Practice and Patient Safety: The Healthcare Team Experience

Figure 2. Antecedents, Attributes, and Consequences of Distracted Practice

Antecedents:
Available cognitive resources
Engaged in practice activity
Cognitive workload
Stimulus occurs

Distracted Practice
Attributes:
Human experience
Aware of stimulus
Continues to perform activity
Within a context or setting
Completed task
No error

Near Miss
Consequences Error caught

ERROR:
reaches the patient
determine degree
of harm from none
to death

Table 1. Observed Unit Characteristics

Unit observed Unit characteristics

Pharmacy #1 21 pharmacists, support the campus where the NICU and surgical unit are located
Intensive care unit—Neonatal 50-bed NICU, divided into 5 pods, serves neonates born in hospital and transported
in from other hospitals in central Massachusetts, 118 RN staff, 10 MD staff
neonatologists, and a designated unit-based pharmacist
Surgical unit 25-bed unit, 11 semiprivate and 3 private rooms, 75 RN staff, covered by various
surgical physician teams
Pharmacy #2 32 pharmacists, support the campus where the adult ICU and medical unit are located
Intensive care unit—Adult 15-bed adult ICU, 65 RN staff, covered by various medical physician teams, and a
designated unit-based pharmacist
Medical unit 28-bed medical unit, 12 semiprivate and 4 private rooms, 82 RN staff, covered by
various medical teams, and a designated unit-based pharmacist

Sample and Setting participants. Sampling represented all three disciplines

(Table 2).
Observations of RNs, MDs, and pharmacists were
conducted in various settings across an academic
medical center (AMC) in Massachusetts. The study site Data Collection
is a 750-bed AMC that had 1,982 RNs, 1,067 MDs,
and 63 pharmacists practicing in the acute care setting Observations
as of April 23, 2014. Units were selected to provide
maximum variation across the diversity of units in the The observation sessions were designed to focus on
acute care setting (Table 1). the four key defining attributes of distracted practice
The observation units provided the basis for active (D’Esmond, 2015): (a) being a human experience;
recruitment for interviews. Direct conversations with (b) the individuals being aware of a stimulus drawing
RNs, MDs, and Pharm Ds were used to identify away their full attention; (c) the individual continuing
initial volunteers for participation (N = 23). Snowball to perform the current activity without suspension
sampling (Lincoln & Guba, 1985; Richards & Morse, to take on another activity; and (d) the experience
2007) was effective in recruiting nine additional study occurring within a specific context or setting.

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in the observation, and if any new or additional

Table 2. Interview Participant Demographics
questions needed to be considered for the next
Participants interview or observation.
Characteristics N = 32
Procedures
Age, years
Range (years) 25–67
Sex Copies of floor plans and staffing plans were
Female 22 (69%) obtained for each department being observed. While
Male 10 (31%) observation was permitted in all areas of each of
Role the departments, including the patients’ bedsides,
Nurses 38% sessions focused mainly in the open areas where
Age range 25–59
Years of experience 3.5–29 staff were more readily observed in the performance
Years at facility 0.5–37 of their work. Observation sessions were clustered
Physicians 34% and alternated with participant interviews. The order
Age range 31–62 of the unit observations and participant interviews
Years of experience 2.5–29 within the clusters varied. The clustering, however,
Years at facility 1.5–27.5
Pharmacists 28% was purposeful and provided ongoing context for data
Age range 26–67 collection and analysis throughout the study and was
Years of experience 0.75–40.8 repeated until saturation was reached.
Years at facility 0.5–14.75 On arrival to the department a brief conversation
Discipline with the person in charge identified current patient
Nursing N = 12/38%
Medicine N = 11/34% volumes and staffing levels and was followed by
Pharmacy N = 9/28% a walk through the unit to assess the existing
activity level. Identifiers used: role, gender, type and
color of clothing, and hair color of staff working
in the department would then be entered onto the
The observation sessions were scheduled with the observation guide and used as a means of identification
department manager and posted on the unit 1 week throughout the session. During the first observation
in advance. The sessions were scheduled to ensure sessions, staff appeared somewhat apprehensive that
that observations would take place across all shifts, they were going to be observed, but within 45 min
on different days of the week, and at different the staff settled in and appeared to no longer be
times. Sessions ranged in length from 35 min to affected by the presence of the principal investigator
2 hr and 10 min, with the average lasting about (PI). Once the staff got to know the PI and fully
1 hr and 20 min. The shorter sessions were at the understood the purpose of the observations, this time
end of the study when nearing saturation and used period became shorter and in some of the last sessions
for confirmation. Observations were clustered and nearly eliminated. The shortening of this initial settling
alternated with interviews so that ongoing validation in time may have also been related to the experience
between observations and interviews throughout and comfort level of the PI. Once familiar with each
the study could be maintained. “Best times” for unit’s “normal” activity, it became easier for the PI to
observation sessions were recommended by staff focus on observing the staff performing their work and
participating in the interview portion of the study the situations of distracted practice they encountered.
and yielded many opportunities to observe distracted
practice among the healthcare team members. Interviews
An observation guide was used to ensure the
consistency of the observation process as well as the Eligibility criteria included any RN, MD, or Pharm
documentation of each session. At the completion D employed at the study site, working in the acute
of the observation session a contact summary form care setting, and who had worked for 6 months after
was used to record the main issues identified. The completing the orientation period. Participants were
form summarized the information observed or missing also able to speak and understand English and capable
related to the attributes and characteristics of distracted of participating in a 60-min interview. Face-to-face
practice, what was salient, illuminating, or important interviews were scheduled at convenient times and

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L. K. D’Esmond Distracted Practice and Patient Safety: The Healthcare Team Experience

not during work hours. Private conference rooms research drive with access only to the PI and the
and offices were used to ensure the participants’ dissertation chair.
comfort to speak freely. A brief questionnaire was
administered to collect sociodemographic data (age, Data Analysis
gender, number of years/months of experience in their
profession, and length of time working in their current Data analysis was carried out using Miles and
role). Additionally, there were two queries on the Huberman’s traditional/conventional approach (Miles
questionnaire related to their experience filling out & Huberman, 1994). This included inductive, constant
an occurrence report following an adverse event. In comparison between observations and interviews to
addition to using dual digital audio recordings, to tape identify themes and subcategories for words, phrases,
each interview session, field notes were also used to passages in the transcripts, and notes on observations.
record observations of the participants, responses to Transcript and contact summary forms were also used
questions, and any additional pertinent information, throughout the process to reflect and identify emerging
including any reflections. themes.
Once the researcher reviewed the purpose of the Data were coded using an iterative process and
study, and ensured that all questions had been repeated to discover the nuances as well as to identify
answered completely and informed consent was the overall theme and subthemes. Excel spreadsheets
obtained, the interview began. A semistructured were used to compare demographics and data that
interview guide was used to conduct the interviews were coded and extracted from summary forms from
and started with a grand tour question: “Can you both observations and interviews. A role-ordered
please take a few minutes to think about a time when matrix was also used to characterize the antecedents,
you observed someone who was being distracted and yet attributes, and consequences of the distracted practice
continued to perform their work? And/or perhaps a time experiences and was beneficial in identifying emerging
when you were being distracted and continued to perform themes.
your work? Try to remember as much detail as possible about Hand coding using colored pens and printing of
these events.” Depending on the aspects of the situation transcripts on colored paper and displaying quotes on
described, additional probing questions were used to a work board were also used to facilitate the coding
elicit additional information. process. This was done until saturation was reached
and quotes were selected to represent key findings.
Member checks were conducted with a
Data Management
representative of each discipline to validate the study
findings. This included a review of the summary
Observation Data
findings and discussion. In each instance the
participant stated that the summary had captured
Observation data were recorded during and
the experience of distracted practice. One participant
immediately following each observation session (Polit
stated defining cognitive resources for the reader
& Beck, 2012). These included completion of the
would be beneficial.
contact summary form and expansion of field notes.
Ongoing comparisons between units and observations
Results
were made and recorded in contact summary forms, a
reflective journal, and later used for analysis.
The sample of acute healthcare providers recruited
for this study included: 12 RNs, 11 MDs, and 9
Interview Data pharmacists (Table 2). The overall mean age was 44
years. The mean age for each discipline was nursing
A unique research identifying number was assigned 47.5; medicine 45.4; and pharmacy 37.8. While 87% of
to each study participant and placed on all data the participants had completed an occurrence report,
including audiotapes. The audiotapes were transcribed only 26% identified distractions as a precursor to the
verbatim by a professional transcriptionist and event. Distracted practice was found to occur in all
reviewed by the PI to check for accuracy. A summary roles observed and clinicians interviewed (RNs, MDs,
of each transcript was completed utilizing a transcript and Pharm Ds) and taking place in all departments
summary template. All data were stored on a secure represented in this study. Distracted practice was found

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Specifically, the analysis of the qualitative data

Table 3. Noise in Acute Care
suggested that there was one main theme, lack of
Voices available cognitive resources, and four subthemes:
Phones: Ringing, text message sounds (a) Individual Differences; (b) Environmental
Pagers beeping Disruptions; (c) Team Awareness; and (d) “Rush
Overhead pages: Codes being announced Mode”/time pressure. Members of the healthcare
Patient call lights and unit clerk answering them and
speaking with patients
team in the acute care setting experienced distracted
Alarms: Tab, telemetry, IV pumps, doors practice on a daily basis. The main theme and
Music subthemes will be discussed in detail as follow.
Normal unit activity: Staff, huddles, teams rounding,
consults from other disciplines Lack of Available Cognitive Resources
Delivering supplies: Linens, food trays, medical
equipment, office supplies
Picking up of used supplies: Soiled linens and trash The experience of distracted practice was based on
Visitors the cognitive resources available at any given moment.
Transport of patients The level of available cognitive resources fluctuated
Team rounds throughout the day based on the individual, the work
Cleaning activities: Emptying the trash and soiled being performed, the location where the work was
linen, “Zamboni” floor cleaning machine
Other: being done, the team the individual was working with
Computer equipment: Telemetry, IV pumps, in the performance of the task, and the time frame to
(technology) complete the task. Having enough cognitive resources
Ventilators to remain focused on the task being performed and
Work stations on wheels completing it effectively was the determining factor for
Pyxis beeping
Blue card stamper experiencing distracted practice.
Fax machines
Pneumatic tube
Ice machine Life happens and there is always going to be
multiple different influences entering somebody’s
brain. At a point where those multiple influences
end up preventing somebody from performing
to occur at all times of the day and night (24/7) their task which they are engaged in, in the
and every day of the week, including holidays. The present moment, optimally then I would say that
distracted practice experience varied by the individual they would have to say that would be distracted
within the context of the practice setting/location practice.
where the work was being performed.
There were 22 observation sessions completed Individual Differences
between December 29, 2014, and June 12, 2015,
totaling 29 hr and 20 min. Each of the six departments Distracted practice is an individual human
was observed on three or four separate occasions experience. The frequency with which any member
following information sessions conducted at each of the healthcare team experiences distracted practice
of the department’s staff meetings. Analysis of the depended upon a combination of factors. Available
observation data revealed conversations (both patient cognitive resources vary from person to person
related and personal), noises, especially from phones, and are influenced by physical health, emotional
and environmental design as being the most significant factors, and mental state, based on the individuals
issues contributing to distracted practice (Table 3). The themselves. Study participants suggested that their
observations provided the foundation for identifying available cognitive resources were affected by having
the many distracting stimuli occurring in each of time to exercise, lack of sleep, being worried about
the departments and led to modifying the interview a sick child or parent, or being consumed by grief,
to capture the strategies participants were using to financial, or relationship issues. One participant
deal with observed mounting distractions. Data from stated: “I think it varies on the person, how easily
the observation sessions were integrated with the distracted they are or they can focus more with stuff.”
interview data to form the thematic study findings that Another mentioned “It’s almost hard not to bring your
follow. personal issues sometimes to work . . . maybe there is

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100 other reasons why their mind isn’t quite there.” An individual’s competence and confidence in the
Distractions were also found to “stack” up, resulting in role being performed further affected his/her ability
a cumulative effect over the course of the work day. to handle distracted practice and this was based on
Distracted practice occurs when persons were experience. One participant identified being distracted
engaged in the performance of their work. The over the concern about what questions their colleagues
incidence of distracted practice varies with the work would ask them and how they would be judged when
day, the overall cognitive demands of the role they reflected on completing their orientation: “okay
being performed, the total assignment (number of they say I’m ready, who can I ask these questions to
patients they were responsible for), patient acuity, the that aren’t going to judge me . . . That’s one of the
complexity of the current task, and the remaining biggest distractions!”
available cognitive resources for completing it. In Another person stated:
general, all healthcare professionals practicing in the
acute care setting of the AMC who participated in this I used to be distracted with Oh my God what are
study had a high cognitive workload demand. This they going to call me for, am I going to be able to
was in part based on the learning environment of the handle it, and now after having done it for almost
AMC, the multiple levels of learning across each of the 20 years I feel pretty good about being able to
disciplines participating in the study, and the stretched handle it. So I think in a lot of ways it gets easier
resources currently being experienced. Each role had with experience.
responsibilities and performance expectations in the
delivery of safe patient care. Individuals were also found to have been
interrupted to the point of experiencing distracted
It happens on a daily basis. These could be practice by emergent events that did not go or end
distractions from electronic devices, from noise well, such as the death of a patient, especially if there
levels, in the working environment, it could was an emotional component (e.g., being a young
be distractions from individuals addressing at patient, close to the family, or caring for this patient
the time where you are focused and engaged for a long time). Then the event continued to occupy
on patient care and the question is how the cognitive space in the individual’s mind and led to
individual deals with these distractions, how distracted practice. “So that distracts you for the rest of
they’re processed, how they are prioritized and the, you know it’s on my mind, could I have handled
how you maintain focus and sometimes we don’t it better or what could I, you know how could I have
and that is when you see undesired events. done it better . . . ” and “then when you get back to it
sometimes you feel like you’re kind of lost and have
Distracted practice often occurred when people to reorganize yourself.”
were waiting (e.g., waiting for the computer, waiting
for someone on the phone). While waiting, staff Environmental Disruptions
frequently attempted to fill the time by performing
other tasks. This attempt at multitasking decreased Environmental disruptions produced a variety of
the available cognitive resources and often led to a external stimuli resulting in distracted practice.
distracted practice experience. One participant stated: How can you work in an environment like this
where it is so noisy and you’re actually making
It happens all the time, You’re writing admission very serious medical decisions and alarms are
orders and somebody comes and starts talking going off, people are having conversations about
to you about a different case where they need something else right next to you and that’s all
an urgent answer or they think they need an distracting.
urgent answer so you’re still writing the orders
but also listening to what they are talking about One participant described the environment, “It’s like
or you could be on the phone answering a going into a locker room at half time, you know it’s
page while you’re multitasking looking up patient like everything is going on at once.” The disruptive
information but also talking to somebody else stimuli in a given area varied depending on the
about patient care so it happens multiple times on environmental design, need for renovations to support
a given day. the current work, size, space limitations, number of

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Distracted Practice and Patient Safety: The Healthcare Team Experience L. K. D’Esmond

people working in the space, type of activity being for the quality of the care that we deliver and
performed, and the technology and equipment being the quality of the patient experience on the other
used, along with sounds/noise and smells. The number end. The quiet hospital initiative or the quiet time
one distracting stimulus was noise, and each unit had initiative, I think it all ties directly into the same
its own usual noise. Table 3 is an inclusive list of noises problem, and it’s all the same thread.
both observed and referred to in the interviews.
One subject described the issue with noise as follows: Telephones ringing were frequently mentioned as
“You know after a while there is just the normal sound a source of noise that resulted in distracted practice.
but the box picker obviously it just goes back and forth “The phones never stopped ringing and at one point
like you are in an amusement park.” And “you get used in time, each of the three of us had two phones to
to the noise, you just block it out, but sometimes it’s so our ears, we were talking to two people at the same
loud you can’t.” time because the phones never stopped ringing” and
During observation sessions the sound of the “you’re going to have one of those phone calls coming
human voice was the number one stimulus at a very critical period and it may well distract you.”
resulting in distracted practice when observing Another participant stated:
staff in every department. Conversations observed Does it distract you? Of course because that’s
included clarification of orders, team rounds, second going to keep ringing and some of us we all are
checks, clarifying/confirming questions, personal probably impatient you know, you are dealing
conversations, cell phones being used, transporters with a group of people who are literally inpatient
talking to patients as they pushed them in wheel for everything so if you dial this and it doesn’t
chairs or on stretchers, and care-related discussions. work within a minute they get you paged.
Depending on how many people were in an area and
the numbers/volume/intensity of the conversations During observations and interviews one thing
being held, the volume could be an extremely became clear: there were fewer distracted practice
distracting stimulus. This was frequently noted by staff episodes where there was less noise and the unit was
glancing up from their work to see what was going quiet.
on. One staff member was observed talking to herself
as she carried out the work, during an intensely busy Team Awareness
time. It appeared as if staff were speaking aloud on
purpose using it as a tool to help them remain focused Participants identified the team they were working
on their task at hand and seemed unaware that they with as a significant factor in one’s ability to effectively
were adding to the already quite loud choir of voices. manage the multiple distracted practice experiences
One person stated: encountered on a daily basis. “Your first obligation is
to your patient and the team of people with whom
You could have a quiet environment where you’re you’re working,” and “the better defined the roles
working and then somebody else starts to have a of the people involved, the less distractions.” Each
conversation right next to you, not to you, but with patient’s current acuity and complexity determines the
somebody else, and depending on how loud they’re size and make-up of the team needed to effectively
talking and what they’re talking about, that can care for them. The larger the team, the greater
definitely be distracting. the challenge of successfully caring for our patients.
One example of normal unit noise and its Team awareness was of critical importance to the
relationship to distracted practice is music in the safety culture, and keeping our patients safe and was
operating room. One participant stated: evidenced by the many near-missed events discussed
in the interviews. There were many instances where
It’s really important to explain why the music another team member, sometimes from a different
should be turned down at key portions of a discipline, identified the missing part of an order,
procedure, just like when an aircraft is starting wrong medication or dose, and kept it from reaching
and landing. There has to be a whole lot more the patient: “Sometimes I think it is really amazing
education on a systematic level because providers more things don’t happen honestly because it is just
don’t necessarily understand the rationale of why so busy.” Participants also mentioned the positive
it is important to decrease the level of distractions impact and value experienced team members had

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L. K. D’Esmond Distracted Practice and Patient Safety: The Healthcare Team Experience

on decreasing distractions and making a challenging This can be caused by a sudden change in a patient’s
patient situation more manageable. Teams that had condition, an emergent issue (code blue, trauma),
greater experience working together were identified as sudden increase in patient volumes without adequate
being more familiar with critical aspects of each other’s beds and/or staffing, or just trying to complete all the
roles, and were able to assist each other when needed necessary tasks before the end of a shift. All these
and provided support and understanding. situations placed a degree of time pressure on the
team and caused an individual to go into “rush mode.”
There are many days where somebody says I’ve Timing was often found to be an antecedent to a
been awake since three in the morning, just be distracted practice experience and was described by
my wingman today make sure we are all on top one person as, “I just feel like if there was more time,
of things so you know we do work together to try less distractions, where you’re not trying to multitask,
and make sure things go right for our patients. listening to the case, reviewing the records, answering
other questions you can focus better.” Another person
Another participant identified a different aspect of said:
team awareness and its negative impact on safety
culture: It’s like a threshold essentially of your distractions
of what you’re able to process and able to do.
Something interesting about the culture here, it Maybe you can handle 10 distractions every 5
seems like everybody is approachable at all times minutes but if it gets to 15 that is when you are
kind of a thing . . . I will be having a conversation just overwhelmed and there is that point of chaos
with you and then someone else will come over and I can’t control this right now.
and start initiating another conversation I’m like
well I’m in the middle of one interaction here . . . When working together in teams, having enough
I don’t know if it is just bad manners or what but time for each person to perform their task effectively
I find that distracting. was an essential component in preventing distracted
practice.
Another component of team awareness was the
emotional status of each team member and its impact Strategies to Decrease Distracted Practice
on the team. “The emotional distractions can be
quite interesting even with colleagues and coworkers, Participants identified many strategies they used
you never know what kind of day they’re going to help in decreasing distractions and preventing
to have.” Overall, teams that were experienced in distracted practice, allowing one to remain focused on
working together and also had good communication the task at hand. These included taking deep breaths,
were seen as having a positive patient safety culture. stepping away, and secluding oneself. Table 4 is a
Wherever this type of patient safety culture was found complete list of identified strategies.
it allowed the team to function with an awareness While distracted practice was found to be a common
to prevent distracted practice or identify and correct experience of healthcare team members in the acute
issues resulting from it. care setting, none of the participants had received
any formal education related to handling distractions.
“Rush Mode”/Time Pressure Distractions and how to minimize them has not
been included in our healthcare training programs
The time in which a task needed to be completed was (Oldach, 2003). Experience was identified as the
another factor that “stacked up,” taking some of the method of learning. This was in addition to any
available cognitive space and diminished the resources helpful hints or tools that may have been provided by
that may be needed to complete a task. staff overseeing them when orienting them to his/her
new role. As a result, it takes each member varying
I think you start to reach a point sometimes degrees of time to learn how to manage distracted
it’s when one distraction adds upon another, practice. This educational gap unfortunately leaves
upon another, upon another, sometimes even the new staff vulnerable, and it is often a distracted practice
smaller ones will get to you so I think there’s some experience resulting in a near miss or adverse event,
that are worse than others but they have that sometimes resulting in harm to a patient, that becomes
additive effect. the first teacher. Participants stated, “If something

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Distracted Practice and Patient Safety: The Healthcare Team Experience L. K. D’Esmond

happens you have to make sure it does not happen

Table 4. Strategies for Dealing With
again” and “let’s take that information and apply it
Mounting Distractions and Avoiding
to prevent it from happening in the first place and
Distracted Practice
developing teaching tools and guidelines to make sure
The individual: we don’t get there in the first place.” These events
Come to work prepared, having exercised, bring food also come at a significant emotional cost to anyone
with you who experienced one, even a near miss, participants
Seclude yourself, go to an area away from all the noise described it as “horrible, just horrible” and identified
and activity
Close doors to decrease noise
it as “taking quite some time” to get over. During that
Leaving your agenda at the door time the experience becomes an emotional factor on
Stepping away, going for a brief walk off the unit the list of things that stack up in an individual’s mind,
Quiet time strategies leaving less available cognitive space for the daily
Creating distraction-free zones, red zones work. This was expressed by one participant stating:
Deep breathing
Debriefing after events What happened? And did I do everything I was
Ensuring breaks for all staff on all shifts
supposed to do, and by the way, hello I’m here to
The physical environment:
Correcting defects in the environment, for example,
take care of you, and let’s finish what we started
location of equipment and size of space to but yet my mind is still back at did I pick up on
accommodate multiple functions and individuals everything, did I do what I had to do? How could
Decrease waiting times: I have made that better? Was there an opportunity
On the computer–single EMR–all information for me to prevent that?
immediately available
The team: Table 5 is a list of the educational recommendations
Knowing who is on your team and each person’s level of made: “educate everyone staff, visitors, and families
experience both in the role and within the organization
about distractions and their impact on safety.”
Basic manners, don’t interrupt when others are speaking
Behavior check lists, what to expect and how to handle “Raise awareness so everyone becomes mind-full of
it behaviors, especially those causing distractions.” One
Identify/know who can be interrupted and when in their educational strategy is teaching everyone to slow
process down, which is counterintuitive when one is under
Better define the roles of the members on the team and
time pressure.
the standard expectations
Better on boarding of LIPs and the proper process of Table 6 summarizes the context, antecedents,
writing orders and being checked for competency stimuli, and consequences of distracted practice from
Establishing standard work where able this study.
Having all the information before paging someone on
your team: Preliminary Model of Distracted Practice
Asking what the patient wants or needs before calling
someone else (e.g., patient needs a pillow)
If in pain the location and intensity as well as recent Data from this study were used to develop a
vital signs before calling the LIP preliminary model of distracted practice that could be
Using text messaging used for further research and education on this topic.
Responding immediately to pages or calls The following model (Figure 3) reflects the distracted
Identify who in your work team you can ask questions of practice experience of individuals across the healthcare
Identify a mentor to check in with once off orientation
Learn something about your coworkers to connect with team in the acute care setting. Distracted practice
them on building a relationship negatively impacts patient safety when consequences
Identify an emotional mentor, “lifeboat,” work buddy to reach the patient, or cause another member of the
communicate with, have a no judgment zone healthcare team to make an error. Distracted practice
Time: potentially diminishes the safety culture across the
Time management organization.
Developing a system for timing of the responses needed
from pages and or text messages
Discussion
How to get timely assistance when the work load
is increasing, distractions are stacking up, and time
pressure is mounting. The purpose of this study was to explore the
experience of distracted practice with physicians,

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L. K. D’Esmond Distracted Practice and Patient Safety: The Healthcare Team Experience

they are working with. Depending on where in the

Table 5. Education Suggestions for Dealing
process this shift in thinking occurs, it may result in
With Distractions and Preventing
missing one or more critical steps or components of
Distracted Practice
the task being performed, with the outcome being
Educate everyone on staff, visitors, and families about incomplete orders, missed documentation, medication
distractions and their impact on safety dispensing or administration errors, and/or incomplete
Raise awareness so everyone becomes mindful of hand-offs. Each episode of distracted practice has
behaviors, especially those causing distractions the potential to reach the patient and/or impact
Teach members of the healthcare team:
a team member somewhere downstream. Systems
r When to say “no”
r When time pressure increases, teach everyone to
require multiple team members/disciplines and roles
“slow down” to avoid error
to effectively work together to safely carry out
r What to do when becoming stressed and patient care activities. Medication preparation and
overwhelmed administration, monitoring, and documentation are
r How to handle coworkers and colleagues when they one example. Distracted practice can occur at any
become stressed and overwhelmed
r How to compartmentalize
point or moment in time, within any of the multiple
r How to ensure follow-up loops are closed after events
systems across the medical center (patient registration,
to avoid reoccurrence diagnostic testing, and nutrition services, just to name
r About selective hearing and the risk of mentally a few). Each individual episode of distracted practice
turning off certain sounds in our minds can potentially impact patient safety, resulting in an
r About culture change and how to eliminate error that may be identified/caught and corrected
resistance to change
r Develop a tool kit that includes:
without error or prior to reaching the patient (near
Priority setting misses). Errors not identified until after reaching the
How to triage ongoing work activities patient can potentially result in permanent harm or
r Time management even death as the result of a single episode of distracted
r Pulling yourself away from the place of activity back practice.
to a place where you can regroup
r Safe place to vent feelings
We found that distracted practice is experienced
r Check lists, so everything is written down and at some point by all healthcare professionals.
crossed off when completed Participants felt it was occurring daily across the
medical center. The lack of available cognitive
resources needed to perform a task was found to
be the key controlling factor leading to distracted
practice and the consequence of error. Participants
nurses, and pharmacists to describe its characteristics described distractions as stacking up and negatively
and to develop a preliminary model for use in affecting their performance. This is consistent with
future studies related to patient safety. Distracted recent studies whose investigators have shown
practice is an individual human experience that increasing distractions and workload to affect
occurs when there are not enough cognitive resources performance and lead to error (Ahmed, Ahmad,
available/remaining to effectively/safely complete the Stewart, Francis, & Bhatti, 2015; Holden et al., 2011;
current task at hand. In that moment individuals Wheelock et al., 2015). Ahmed et al. (2015) studied
shift from thinking critically, being able to complete physicians performing a surgical task and found errors
their current task without error, to not thinking increased with increasing distractions. Wheelock and
critically and working in an automatic mode. In colleagues observed 90 cases in the operating room
this automatic mode individuals may only be going and found distractions to definitely affect members
through the motions and not thinking critically. While of the team and their performance. Equipment
in automatic mode, individuals rely on formed work distractions increased stress and lowered teamwork
habits, either good or bad. Without thinking critically, in nurses, while acoustic distractions increased
potential warning signs, changes in condition, or the stress level of surgeons and the workload of
vital pieces of information may not be recognized anesthesiologists (Wheelock et al., 2015). Our findings
and ultimately missed. This is the point at which are also similar to those of Holden and colleagues,
an individual’s experience in the current role is who looked at nursing workload and its impact
a major factor, as is the experience of the team on patient outcomes and found that task level and

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Distracted Practice and Patient Safety: The Healthcare Team Experience L. K. D’Esmond

Table 6. Context, Antecedents, Stimuli, and Consequences of Distracted Practice

Context Antecedents Stimuli Consequences

Environment: Available cognitive resources External stimulus: Completed task/No error

Specific location Varies by individual Visual
Unit design Varies day to day Auditory
Size of space Varies throughout the day Olfactory
Work being done Tactile
Technology
Working conditions: Being engaged in a practice Internal stimulus: Error caught prior to
Patient volumes activity/work Any intrusive thought not reaching the patient/Near
Staffing/workloads related to the current miss
Staff experience activity
Rushing/time pressure
Circumstances: A stimulus occurring that the Stress: Error reaches the patient
Policies/procedures individual may or may not Anxiety No harm
Safety culture be aware Grief Harm
Barriers to efficiency Time pressure Degree of harm

Figure 3. Model of Distracted Practice Model

mental workload were related to interruptions, that the inter-relatedness of the four subthemes—
divided attention, and being rushed (Holden et al., individual differences, team awareness, environmental
2011). disruptions, and time pressure—were important
While available cognitive resources were the considerations. It is the combined effects of these
key contributing factors, this study also revealed factors that result in distracted practice. These four

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L. K. D’Esmond Distracted Practice and Patient Safety: The Healthcare Team Experience

subthemes from our study are similar to the four staff, patients, and families. For staff this can be
fundamental elements of situation awareness: the accomplished through learning sessions, discussions
patient, the environment that includes the physical at staff meetings, and safety huddles that hopefully
surroundings and the human environment/team, the will positively affect patient safety by increasing
task being performed, and time. Situation awareness individual and team knowledge. For patients and their
is the cognitive state of being aware of what is families, understanding the issues related to distracted
going on around you (Edozien, 2015). Endsley and practice is important to ensure safety and improve the
Garland (2000) defined it as having three levels: quality of care being received. Discussing distracted
“the perception of the elements in the environment practice during admission procedures and providing
within a volume of time and space (level 1), the patients and families with written information are
comprehension of their meaning (level 2), and the possible ways of disseminating this vital information.
projection of the status in the near future (level 3).” For example, teaching patients and families about
Many study participants also noted distractions and distracted practice and cautioning them to avoid
distracted practice happened in levels from minimum nonurgent conversations when the healthcare team
to severe. member is administering medications or performing a
The framework used to guide this study was procedure.
useful for capturing and describing the distracted Education interventions to reduce distracted practice
practice experience (Figure 2). It was developed using will need to consider cognitive load theory and
the distracted driving model (Strayer et al., 2013) the cognitive training approaches recently developed
and a recent concept analysis of distracted practice that selectively target and improve processing from
(D’Esmond, 2015). The framework provided the external and internal distractions (Kaylor, 2014;
necessary structure and background to evaluate the Mishra, Anguera, Ziegler, & Gazzaley, 2013; Young,
context, antecedents, stimuli, and consequences of Van Merrienboer, Durning, & Ten Cate, 2014). For
each of the distracted practice experiences observed example, cognitive load theory is based on the degree
and discussed during the study interviews. We of learning interference associated with the effort
found that participants were often confused between required by the learner in thinking and reasoning,
interruptions, distractions, and multitasking. While with some environments demanding more effort
each situation utilizes some available cognitive than others. Cognitive load theory further suggests
resources and may be a precursor to distracted designing the information to be learned to avoid
practice, each affects the individual experience of cognitive overload and advocates using different
distracted practice differently and needs to be clearly design strategies and teaching approaches for novice
understood so it can be avoided. In addition, we also staff from experienced ones (Kaylor, 2014; Young
learned that participants were not always aware of the et al., 2014). We may need to rethink educational
stimuli that caused distracted practice. For example, efforts being conducted on the units during work
participants were observed not responding to alarms, time and separate staff based on experience to
patient call bells, or telephones ringing; they also attend sessions in conducive environments that
recounted in interviews needing to focus so intensely maximize their learning. Mishra et al. (2013) have
on what they were doing that they “blocked out” recently developed several computerized cognitive
sounds in the environment. However, the noise was training programs. One program demonstrated a 50%
still occurring and additional cognitive effort was decrease in distractibility while another improved self-
being exerted to pay no attention to those sounds. awareness and regulation of attention by suppressing
internal distractions. In a recent study, Thomas
Implications for Practice et al. (2015) showed that medical students were
not equipped to handle the common distractions to
Decreasing and/or eliminating distracted practice avoid error and demonstrated that these skills could
among members of the healthcare team in the acute be taught using simulation. Integrating simulation
care setting will ultimately improve patient safety. experiences into education for healthcare staff is
Educational efforts are needed to raise awareness recommended (Thomas et al., 2015).
and teach everyone about the loss of situational Participants identified feeling unprepared to
awareness leading to distracted practice and its impact deal with the mounting distractions in the acute
on patient safety. This education is needed for all care setting. Some of the strategies used by study

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Distracted Practice and Patient Safety: The Healthcare Team Experience L. K. D’Esmond

Table 7. Participant Strategies to Avoid Distracted Practice and Ways to Improve Situation
Awareness

Participant strategies to avoid distracted practice Ways to improve situation awareness

Improve task management: Level 1

Seclude yourself Avoid interruptions
Create distraction free zones Avoid task-related distractions
Close doors to decrease noise Avoid other non-task-related distractions
Know your team and their experience Manage overall workload
Improve development of comprehension: Level 2
Time management Be aware of timing
Responding immediately to text messages and pages Continually evaluate the risk
Better define roles of team members Be aware of capabilities
How to get timely assistance Be aware of potential consequences and severity
Projections and planning: Level 3
Having all the information Seek out critical information
Behavior check lists, know what to expect and how to handle it Be aware of cues
Identify who in your team you can ask questions of Anticipate possible future occurrences
Identify a mentor to check in with Develop contingency plans

participants to deal with increasing distractions distracted practice are also needed. Additionally, a
and avoid distracted practice are similar to measure of distracted practice will be beneficial to
those used for improving situational awareness assist individuals in developing self-awareness and
(Table 7). One example of a key factor used to recover implementing strategies and interventions to reduce
situation awareness when it has been lost is taking distracted practice and ultimately reduce errors.
time to think (Guerney, n.d.). In situations when
staffing is low, patient volumes are high, acuity is
Limitations
increasing, situation awareness is being lost, and
distracted practice is happening, it is not intuitive
There are several limitations to this study. Results
for staff to take time to think. The power of slow
are limited to one AMC, involving six departments
thinking requires disciplined thought, and Kahneman
and three interdisciplinary roles. Future studies may
(2013) argued against swiftness, asserting that it
involve multiple sites, more departments, and include
is the slowness of thinking that actually results in
all roles working within the department. Health
better decision making (Kahneman, 2013). One study
professionals who were willing to participate in this
by Moulton and colleagues involved 28 surgeons
study may be different from those who chose not to
across various specialties using grounded theory to
participate in terms of their awareness of distracted
develop a framework for slowing down and described
practice. Therefore, findings may not reflect those who
these critical surgical moments as moving from
are less willing to discuss problems with distractions in
the “automatic” to the “effortful” and found the
the workplace.
framework to be essential for teaching, self-reflection,
and patient safety (Moulton, Regehr, Lingard, Merritt,
& Macrae, 2010). Therefore, the skill of slowing down Conclusion
to take time to think needs to be taught, demonstrated,
and role modeled. The experience of distracted practice is the result of
Further research is needed to understand the total limited cognitive resources.
effect that distracted practice has on patient safety Distracted practice:
and to determine the best approaches for helping
practitioners avoid it. Greater understanding of the r is dynamic, temporary, and may be only momentary
levels of distractions generated from each of the r varies by individual and fluctuates day to day
subthemes and their relationship with maintaining r continually changes throughout the day, depending
situation awareness and its impact on avoiding on the workload and level of distractions

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L. K. D’Esmond Distracted Practice and Patient Safety: The Healthcare Team Experience

An individual may or may not be aware of the Guerney, D. (Producer). (n.d.). Gaining and maintaining
stimulus that takes up that last bit of cognitive space situational awareness. Retrieved November 14, 2015, from
pushing him or her into the automatic mode of http://www.skybrary.aero/bookshelf/books/754.ppt
Holden, R. J., Scanlon, M. C., Patel, N. R., Kaushal, R.,
distracted practice. Escoto, K. H., Brown, R. L., . . . Karsh, B. T. (2011).
Distracted practice is an individual human A human factors framework and study of the effect of
experience that occurs when there are not enough nursing workload on patient safety and employee quality
cognitive resources available to effectively complete of working life. BMJ Quality and Safety, 20(1), 15–24.
the task at hand. In that moment, an individual shifts doi:10.1136/bmjqs.2008.028381
James, J. T. (2013). A new, evidence-based estimate of
from being able to think critically, completing their patient harms associated with hospital care. Journal
current task without error, to not thinking critically of Patient Safety, 9(3), 122–128. doi:10.1097/PTS.
and working in an automatic mode. This is when 0b013e3182948a69
errors occur. Increasing awareness and understanding Kahneman, D. (2013). Thinking, fast and slow (1st ed.). New
of the components and consequences of distracted York: Farrar, Straus and Giroux.
Kaylor, S. K. (2014). Preventing information overload:
practice for all members of the healthcare team Cognitive load theory as an instructional framework
practicing in the acute care environment will be for teaching pharmacology. Journal of Nursing Education,
an important first step in assisting each of them to 53(2), 108–111. doi:10.3928/01484834-20140122-03
prevent or reduce the errors resulting from distracted Kohn, L. T., Corrigan, J., & Donaldson, M. S. (2000). To err
practice. is human: Building a safer health system. Washington, DC:
National Academy Press.
Lincoln, Y. S., & Guba, E. G. (1985). Naturalistic inquiry.
Acknowledgments. The author would like to Beverly Hills, CA: Sage.
acknowledge and express her deepest appreciation Miles, M. B., & Huberman, A. M. (1994). Qualitative data
analysis: An expanded sourcebook (2nd ed.). Thousand Oaks,
to her dissertation chair, Carol Bova, PhD, RN, and CA: Sage.
committee, Margaret Hudlin, MD, and Eileen Terrill, Mishra, J., Anguera, J. A., Ziegler, D. A., & Gazzaley, A.
PhD, RN, for their combined guidance, direction, and (2013). A cognitive framework for understanding and
support that helped make this work a reality. improving interference resolution in the brain. Progress
in Brain Research, 207, 351–377. doi:10.1016/B978-0-444-
63327-9.00013-8
Moulton, C. A., Regehr, G., Lingard, L., Merritt, C., &
References Macrae, H. (2010). ‘Slowing down when you should’:
Initiators and influences of the transition from the routine
Ahmed, A., Ahmad, M., Stewart, C. M., Francis, to the effortful. Journal of Gastrointestinal Surgery, 14(6),
H. W., & Bhatti, N. I. (2015). Effect of 1019–1026. doi:10.1007/s11605-010-1178-y
distractions on operative performance and ability Oldach, D. (2003). Rushing, distraction, and anger.
to multitask—A case for deliberate practice. American Journal of Medicine, 114(8), 699. Retrieved
Laryngoscope, 125(4), 837–841. doi:10.1002/lary. from http://www.ncbi.nlm.nih.gov/pubmed/12798461
24856 Pape, T. M. (2003). Applying airline safety practices to
Biron, A. D., Lavoie-Tremblay, M., & Loiselle, C. G. (2009). medication administration. Medsurg Nursing, 12(2), 77–
Characteristics of work interruptions during medication 93. Retrieved from https://www.amsn.org/professional-
administration. Journal of Nursing Scholarship, 41(4), 330– development/periodicals/medsurg-nursing-journal
336. doi:10.1111/j.1547-5069.2009.01300.x Polit, D. F., & Beck, C. T. (2012). Nursing research:
Creswell, J. W. (2007). Qualitative inquiry & research design: Generating and assessing evidence for nursing practice (9th
Choosing among five approaches (2nd ed.). Thousand Oaks, ed.). Philadelphia, PA: Wolters Kluwer Health/Lippincott
CA: Sage. Williams & Wilkins.
D’Esmond, L. K. (2015). Distracted practice: A concept Richards, L., & Morse, J. M. (2007). Readme first for a user’s
analysis. Nursing Forum. doi:10.1111/nuf.12153/abstract guide to qualitative methods (2nd ed.). Thousand Oaks, CA:
Edozien, L. C. (2015). Situational awareness and its Sage.
application in the delivery suite. Obstetrics and Gynecology, Ross, J. (2013). Distractions and interruptions in the
125(1), 65–69. doi:10.1097/AOG.0000000000000597 perianesthesia environment: A real threat to patient
Endsley, M. R., & Garland, D. J. (2000). Situation awareness: safety. Journal of Perianesthesia Nursing, 28(1), 38–39.
Analysis and measurement. Mahwah, NJ: Lawrence doi:10.1016/j.jopan.2012.11.004
Erlbaum Associates. Sitterding, M. C., Broome, M. E., Everett, L. Q., & Ebright,
Feils, M. (March 2013). Distractions and their impact on patient P. (2012). Understanding situation awareness in
safety. Retrieved from http://patientsafetyauthority.org/ nursing work: A hybrid concept analysis. Advances
ADVISORIES/AdvisoryLibrary/2013/Mar;10(1)/Pages/ in Nursing Science, 35(1), 77–92. doi:10.1097/ANS.
01.aspx 0b013e3182450158

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Nursing Forum Volume 00, No. 0, July 2016
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Strayer, D. L., Cooper, J. M., Turrill, J., Coleman, J., Wheelock, A., Suliman, A., Wharton, R., Babu, E. D.,
Mederos-Ward, N., & Biondi, F. (2013). Measuring Hull, L., Vincent, C.,. . . Arora, S. (2015). The impact
cognitive distraction in the automobile. Retrieved from http:// of operating room distractions on stress, workload,
www.aaafoundation.org/sites/default/files/Measuring and teamwork. Annals of Surgery, 261(6), 1079–1084.
CognitiveDistractions.pdf doi:10.1097/SLA.0000000000001051
Thomas, I., Nicol, L., Regan, L., Cleland, J., Maliepaard, D., Young, J. Q., Van Merrienboer, J., Durning, S., & Ten
Clark, L.,. . . Duncan, J. (2015). Driven to distraction: Cate, O. (2014). Cognitive Load Theory: Implications
A prospective controlled study of a simulated ward for medical education: AMEE Guide No. 86. Medical
round experience to improve patient safety teaching for Teacher, 36(5), 371–384. doi:10.3109/0142159X.2014.
medical students. BMJ Quality and Safety, 24(2), 154–161. 889290
doi:10.1136/bmjqs-2014-003272

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