Ms. Lanfranchi's hospital did its first simulation training in February
2013, paired with training in CRM (crew resource management), a
methodology created to improve airline safety but that has since found a
natural extension in surgery. CRM is based on the idea that addressing
the challenges responsible for causing human error — primarily, failures
in interpersonal communication, leadership and decision-making — can,
in turn, prevent the majority of accidents.
The results? The entire OR staff has become more attuned to situa-
tions that could affect a patient's surgical outcome — not only major
issues, like the marking of a wrong site, but also relatively minor
issues, like infiltrated IVs. Communication has improved among
departments, especially between OR nurses and PACU nurses during
handoffs. And the number of harm events has plummeted — and it
has remained low every year since 2013.
Ms. Lanfranchi says the surgical simulation was so well received
that the hospital has since extended the training to include other
issues that can affect patient safety, such as positioning, prepping and
malignant hyperthermia.
Raising the level
As a result of Lt. Naranjo speaking up in the OR last summer, Naval
Hospital Jacksonville has updated its perioperative time out policy.
Now, to ensure that each procedure is performed according to the
signed surgical consent, the whole surgical team — the surgeon, the
surgical tech, anesthesia and the OR circulator — takes a time out
before every procedure that occurs within a single case.
The staff also does a post-operative time out to verify the procedure,
any specimens harvested during the surgery and other pertinent infor-
mation germane to the case. The post-op breather also gives team
members an opportunity to discuss anything they could have done
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