ORX Proceedings
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extremely low error rates — groups such as nuclear power plant operators, infectious disease researchers, aircraft carrier flight decks and S.W.A.T. and special ops teams. What do those groups have in common? High accountability, a preoccupation with understanding and preventing failures, a broad knowledge base and shared information, team training, and strict adherence to checklists and procedures when appropriate, he says.
"Site-marking and time outs should be done for every patient, every time," says Mr. Byrum. "They should be done just before the first invasive move. They should be done well, with everybody involved. It's absolutely your last best chance to prevent catastrophic errors." Communication is key. Between 70% and 80% of mistakes involve communication breakdowns, says Mr. Byrum.
Who should lead the effort? "Having surgeons engaged and leading time outs is where we need to get," he says. The pre-op pauses don't have to be long and elaborate, he adds. "Between 30 seconds and 1 minute is all it should take. The important thing is that they have to be done with focus and attention. No 'never events' is an obligation, not a goal."
— Jim Burger
