place to share insights consistently, openly and honestly.
Learn from near-misses
Systems breakdowns that don't reach the patient are wonderful
learning opportunities. You need to encourage, not punish, staff mem-
bers who have the courage to be vulnerable and discuss what almost
went wrong openly and honestly. Their openness to share what could
have gone better will let us all learn valuable lessons and continue to
advance safe surgical care. The blame-and-shame game, on the other
hand, will prevent providers from admitting they're imperfect and
waste the valuable lessons we can learn from their experiences.
OSM
Dr. Wick (elizabeth.wick@ucsf.edu) is a colorectal surgeon at the University
of California, San Francisco.
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