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F E B R U A R Y 2 0 1 4 | O U T P AT I E N T S U R G E R Y M A G A Z I N E O N L I N E
ger release — a personal trauma he later chronicled in the New
England Journal of Medicine (
tinyurl.com/2f4l4fw
). For Dr. Ring, the
memory is still haunting. "For somebody who's done a wrong proce-
dure, it's a lifetime of doing anything you can to prevent it from happen-
ing again," he says.
Such mistakes are called never events — wrong site, wrong patient,
objects left behind and so forth — but is that a misnomer? With thou-
sands of procedures performed every day, each with hundreds of
attendant variables, is never a realistic goal? "It absolutely is," insists
Spence Byrum, an expert on high-reliability organizations and a man-
aging partner of Convergent HRS in Weston, Fla. "How can it be any-
thing else? These are patients' lives and well-being. It's like a pilot say-
ing I hope I get 9 out of 10 of these landings right."
Of course, setting a goal and achieving it aren't the same, but the
experts we talked to firmly believe that with the right tools and the right
attitudes, surgical facilities can get a lot closer to zero than they are now.
Where it begins
The process starts — or should — long before the procedure takes
place, says Mr. Byrum. "A disproportionate number of wrong sites
have their origins in the physician's office," he says. "It could be an
incomplete handoff, it could be H&Ps or consents that are not signed.
Any time you're dealing with labs, MRIs, CTs, X-rays — if you're trying
to make everything come together just before the surgery, it's very dif-
ficult. Really, that patient should not be in the OR if you don't have
those things complete. Otherwise you're absolutely compressing your
window to make sure you get everything correct."
That rushed approach — what Mr. Byrum calls time compression —
is one of the most significant risk factors, he says. Once you fall
behind, the threat rises.
P R E - O P S A F E T Y
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