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N E V E R
E V E N T S
But we also
know that
those who are
responsible for
implementing
the process
may not understand the
rationale
behind each
step in the
process. So
NO DIFFERENT Nerve blocks should
ensuring they
come with their own, separate time outs.
have a firm
grounding in the evidence or rationale, and can explain it to any
skeptical team members, is paramount.
Wrong events are nearly always preventable. But your facility's culture must support staff who speak up for their patients — and patients
who speak up for themselves. We often see in reports that someone on
the care team knew something was wrong or had questioned something, but was afraid to speak up for fear of the consequences. Protect
your employees, whether in the business office or the OR, to ensure
everyone speaks more readily. OSM
Ms. Rydrych (diane.rydrych@state.mn.us) is the director, division of health
policy, at the Minnesota Department of Health. Ms. Jokela
(rachel.jok ela@state.mn.us) is the division's and department's adverse
health events program director.
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O U T PAT I E N T S U R G E R Y M A G A Z I N E O N L I N E | M AY 2013