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N E V E R
E V E N T S
NO DIFFERENT Nerve blocks should come with their own, separate time outs.
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 ensuring they 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.
