Outpatient Surgery Magazine - Subscribers

OR Excellence 2019 Awards - Outpatient Surgery Magazine - September 2019

Outpatient Surgery Magazine, providing current information on Surgical Services, Surgical Facility Administration, Outpatient Surgery News and Trends, OR Excellence and more.

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S E P T E M B E R 2 0 1 9 • O U T PA T I E N T S U R G E R Y. N E T • 2 9 T he surgeon had signed the patient's left side and was about to begin surgery, but something didn't feel right to the medical student in the room. "Can we check that one more time?" he asked. "I believe the procedure is supposed to be performed on the other side." It was the right call. The team averted a wrong-sided surgery because the person who occupied the most junior rung on the OR lad- der listened to his intuition and felt empowered to speak up. That event came to light during one of our health system's weekly conferences, during which surgical team members gather to review adverse events and discuss what we could have done differently. Our research team engaged with those conferences in 3 hospitals over 6 months to collect and analyze information about 182 adverse events that occurred during 5,365 procedures. We discovered human error was involved in more than half (106) of them. Errors linked to communication, teamwork and system protocols were lower than we expected, indicating team-based approaches such as safety checklists have been largely effective in preventing patient harm. But other human errors — lack of attention, recognition mis- We Don't Need Another Checklist It's time to address the elephant in the operating room: human error. Safety Todd K. Rosengart, MD, FACS • INNER VOICE Surgical professionals must learn to trust their instincts and take personal responsibility for performing safe surgery. Pamela Bevelhymer, RN, BSN, CNOR

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