Outpatient Surgery Magazine

Helping Hand - July 2019 - Subscribe to Outpatient Surgery Magazine

Outpatient Surgery Magazine, providing current information on Surgical Services, Surgical Facility Administration, Outpatient Surgery News and Trends, OR Excellence and more.

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Page 24 of 128

tion results that are significantly discordant with the operative find- ings. For example, if a surgeon biopsies an obviously neoplastic lesion and the result is negative, he should consult the pathologist. Even with this step, it may be impossible to untangle the error. Unfortunately, mistakes happen as results of both human error and technology — whether independent of one another, or combined. This pathologist was aware of a previ- ous error, but she didn't do anything to repair it, other than hope she would catch problems that happened in the future. Unstable clinical processes are prone to error and often lead to catastrophic outcomes. It's easy to fall into bad habits over time, or jadedly accept bad situa- tions and systems without speaking up. But a lot of those situations and systems could be improved with a little communication and collabora- tion. The most important preventative measure your center can take to avoid a situation like the one Iowa Clinic experienced is to encourage all of your personnel to report errors, near misses or any other data point that could result in a patient being put in harm's way. Creating, encourag- ing and adhering to this type of transparent, proactive environment will benefit both your patients and your employees. When staff feel comfort- able reporting problems, or potential problems, a trust for and respect of management is created, and the ultimate beneficiary is the patient. OSM Ms. Stremick (jerene@elitemedicalexperts.com) is the Managing Nurse Case Strategist at Elite Medical Experts in Tucson, Ariz., where she and her physi- cian-led team have consulted on more than 7,000 medicolegal matters. Her clinical expertise is in orthopedics, trauma, critical care, ambulatory surgery and dermatology. J U L Y 2 0 1 9 • O U T PA T I E N T S U R G E R Y. N E T • 2 5 • DON'T MAKE THE SAME MISTAKE TWICE Encouraging the reporting of errors and near misses creates a transpar- ent workplace culture that protects patients from harm.

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