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
