takes and confirmation bias — are unresolved issues in today's ORs
that we need to address, especially when our findings are applied to
known national statistics: If human error, as indicated by our study,
accounts for half of the adverse events that occur in as many as 5% of
the 17 million annual U.S. surgeries, efforts to improve the cognitive
performance of surgical teams could prevent about 425,000 adverse
events each year.
Instead of adding another to an already almost overwhelming num-
ber of checklists designed to prevent the patient harm that continues
to occur, we need to focus more on human performance and teach all
medical professionals to pay close attention to the voice in the back
of their heads that's telling them something doesn't seem right.
New ways of thinking
Checklists are very effective and worthwhile safety tools, but imple-
menting too many of them can result in burnout and ultimately have
your staff checking off boxes of essential steps without engaging in
implementation of them. The task becomes onerous, and the checklist
provides diminishing returns. We must at some point also be able to
rely on our internal checklists to protect patients from harm.
Most facilities have high reliability and structured organization in
place, but opportunities for improvement remain. The more levels of
protection built into a system of checks and balances, the better, but
that doesn't always guarantee errors won't cause patient harm. The
Swiss cheese model of medical errors. According to the Swiss cheese
model of accident causation, a series of safety barriers have inherent
weaknesses and, if the weaknesses align by random chance, errors
can reach the patient to cause harm.
Surgical team members' internal checklists must protect patients.
We need to help individuals improve their own performances by keep-
Safety
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