actual events to run simulation training exercises, which teach
the team to review how they can and should respond when simi-
lar scenarios occur, as we have done with some of our root cause
analyses here at Baylor College of Medicine.
Exercises such as simulation training can provide physicians and
medical staff members with cues about high vulnerability situations
and remind them to focus more intently and listen to their inner voice,
the one that tells them something doesn't feel quite right. The internal
dialogue is ongoing, but without such training, providers may be more
prone to ignore it. Teach members of your team to pay attention to
their intuition. Tell them to pause when internal alerts sound, self-ana-
lyze, speak up and take action if necessary.
Cognitive training can also help teams respond to other cognitive
distractions, even the errant breaks in routine that inevitably occur in
the OR. The training would give surgeons, nurses, techs and anesthe-
sia providers the tools they need to pause, refocus and reengage in
the moment after distractions occur. Such lessons could be applied
throughout all phases of patient care.
Remember the oath
For too long, young physicians and surgeons seem to have been inex-
orably destined to make the same mistakes made by those who came
before them. It's an important exercise to understand why these errors
occur and to learn from them, but it may be even more valuable to train
providers to recognize what leads to those errors in order to avoid them
before they happen.
OSM
Dr. Rosengart (todd.rosengart@bcm.edu) is professor and chair of the
Michael E. DeBakey Department of Surgery at Baylor College of Medicine in
Houston, Texas.
Safety
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