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.

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Page 30 of 144

ing these cognitive improvement strate- gies in mind. • Avoid confirma- tion bias. It's easy to rush to comply with what you expect to see or hear, instead of what is actually present. For example, we in our research encountered a case where a guide wire stylus that had been inadvertently retained following a procedure was "missed" and not reported on radiology reports. Even though the clinicians caring for the patient subconsciously "saw" the wire, they dismissed their own concerns because they were not validated in official radiology reports. One might assume a lack of attention was to blame for the multiple misses, but this deference to the "official" report well highlights the confirmation bias that can cloud our decision making, and in this case led to the repeated failures to act upon correct and important obser- vations. • Focus when it counts most. It might be nearly impossible to per- form surgery with razor sharp focus for the duration of a procedure, but you can zero in on the task at hand during critical stages (anesthe- sia induction, technically challenging maneuvers, implant placement and the counting of objects, for example). We can take a cue from commercial aviation on this. Pilots pay attention during every portion of a flight, of course, but are instructed to avoid all distractions and focus with greater intensity on their responsibilities during the critical intervals of takeoff and ascent and descent and landing — the so called "sterile cockpit" when no extraneous conversation is allowed. • Cognitive training. To improve the cognitive performance of our teams, it is critical that we track the root causes of adverse events and huddle as a group to discuss these errors and how they could have been avoided. One can even use the details of the S E P T E M B E R 2 0 1 9 • O U T PA T I E N T S U R G E R Y. N E T • 3 1 We must at some point also be able to rely on our internal checklists to protect patients.

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