Outpatient Surgery Magazine

OR Excellence 2019 Awards - September 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.

Issue link: http://outpatientsurgery.uberflip.com/i/1164519

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Page 29 of 144

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 S 3 0 • O U T PA T I E N T S U R G E R Y M A G A Z I N E • S E P T E M B E R 2 0 1 9

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