tion results that are significantly
discordant with the operative find-
ings. For example, if a surgeon
biopsies an obviously neoplastic
lesion and the result is negative, he
should consult the pathologist.
Even with this step, it may be
impossible to untangle the error.
Unfortunately, mistakes happen
as results of both human error and
technology — whether independent
of one another, or combined. This pathologist was aware of a previ-
ous error, but she didn't do anything to repair it, other than hope she
would catch problems that happened in the future. Unstable clinical
processes are prone to error and often lead to catastrophic outcomes.
It's easy to fall into bad habits over time, or jadedly accept bad situa-
tions and systems without speaking up. But a lot of those situations and
systems could be improved with a little communication and collabora-
tion. The most important preventative measure your center can take to
avoid a situation like the one Iowa Clinic experienced is to encourage all
of your personnel to report errors, near misses or any other data point
that could result in a patient being put in harm's way. Creating, encourag-
ing and adhering to this type of transparent, proactive environment will
benefit both your patients and your employees. When staff feel comfort-
able reporting problems, or potential problems, a trust for and respect of
management is created, and the ultimate beneficiary is the patient.
OSM
Ms. Stremick (jerene@elitemedicalexperts.com) is the Managing Nurse Case
Strategist at Elite Medical Experts in Tucson, Ariz., where she and her physi-
cian-led team have consulted on more than 7,000 medicolegal matters. Her
clinical expertise is in orthopedics, trauma, critical care, ambulatory surgery
and dermatology.
J U L Y 2 0 1 9 • O U T PA T I E N T S U R G E R Y. N E T • 2 5
• DON'T MAKE THE SAME MISTAKE TWICE Encouraging
the reporting of errors and near misses creates a transpar-
ent workplace culture that protects patients from harm.