tence, says Mr. Duffy, but a much more dangerous source of errors is
desensitization and inattention. Constant exposure to life-and-death
situations day after day after day causes nurses to "normalize the dan-
ger," he says. A combination of complacency and time pressures
results in errors.
To understand how it works, consider "overlearned" skills like driv-
ing, says Mr. Duffy. "When my daughter was first learning how, she
was extremely nervous and had the white knuckles to show for it. By
the time she turned 22, she was flying down (Chicago's) Kennedy
Expressway in heavy traffic, steering with her knees. She believed she
had mastered driving and no longer feared this 2,000-lb. weapon."
During Mr. Duffy's entertaining multimedia exploration of the role
OR leaders play in ensuring a safe environment for patients and staff,
you'll see memorable video clips of real and fictional disasters and
near disasters that occurred not because of incompetence, but
because of inattention. "I believe we remember things we see much
more vividly than things we hear," he says.
Mr. Duffy says he learned that he could hurt patients in his first year
in practice. "A patient had been administered a medication, and it had
been discontinued. However, when I visited the bedside, there was
still another dose in the bin. I glanced at the record but didn't notice
the discontinuation and went ahead and administered the extra dose."
The patient was fine, but Mr. Duffy never forgot that the outcome
could have been different. "Every day, before I entered the OR, I
prayed that I wouldn't hurt a patient that day."
He advises OR staff to heed the warning in the Allstate commercials:
"Mayhem can happen at any time."
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