Impacts of time pressure during the ICU handover safety check of critical care nurses. A randomised eye-tracking analysis

Abstract

INTRODUCTION: Safety checks during ICU handovers are error prone and often affected by stress, particularly time pressure. Standardized handover and safety-check procedures are lacking. We hypothesized that time pressure would negatively affect error detection and visual behaviour in ICU nurses performing handover safety checks. METHODS: We conducted a randomized eye-tracking study in April 2024 in a simulated ICU setting with a standardized patient and predefined hidden errors. All ICU nurses at our institution were invited to participate. Participants were randomized into four groups to assess the effects of time pressure and checklist use on error detection and gaze behaviour. The primary outcome was overall error recognition. Secondary outcomes included eye-tracking metrics (dwell time, entry time, revisits, and first visual intake duration) across predefined areas of interest (AOIs). RESULTS: Ninety-one ICU nurses were included. Overall, participants missed a median of 4 errors (IQR 3.0-5.0), including 3 major (IQR 2.0-3.0) and 2 minor errors (IQR 1.0-2.0). Under time pressure, participants missed significantly more errors (median 5.0, IQR 3.0-6.0) than those without time pressure (median 3.5, IQR 3.0-5.0; p = 0.002). Checklist availability did not significantly affect error detection, with a median of 4.5 errors missed (IQR 3.0-5.0) without a checklist versus 4.0 (IQR 3.0-5.0) with a checklist (p = 0.651). Eye-tracking analysis showed that the probability of missing errors was associated with altered gaze behaviour across all AOIs in time-pressured groups compared to non-time-pressured groups. CONCLUSIONS: Time pressure significantly impaired error detection during ICU handover safety checks, whereas the use of the applied checklist was not associated with a measurable improvement in performance. Eye-tracking data demonstrated that time pressure was associated with distinct gaze behaviour patterns, suggesting altered visual attention during handovers. IMPLICATIONS: Time pressure reduces error detection during ICU handovers, underscoring performance vulnerability under this condition. Strategies to reduce time pressure and assess checklist usefulness, which may improve patient safety, should be validated in further studies.