Outpatient Surgery Magazine, providing current information on Surgical Services, Surgical Facility Administration, Outpatient Surgery News and Trends, OR Excellence and more.
Issue link: http://outpatientsurgery.uberflip.com/i/320931
1 8 O R E X C E L L E N C E. C O M S U P P L E M E N T T O O U T P AT 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 | J U N E 2 0 1 4 perform the trigger-finger release, which went off without incident. The patient was discharged the same day. I apologized to her and her son during numerous follow-up phone calls. The hospital waived all fees and reached a financial settlement with the patient. Other than an unnecessary incision on the palm, there was no lasting harm for my patient. • A cascade of errors. Poor scheduling and inadequate staffing levels caused last-minute changes that added to an already stressful day. The correct wrist was marked, but the incision site on the left index finger wasn't. Plus, the mark- ing was wiped off during the skin prepping. I could communicate with the patient in Spanish, but we should have used an interpreter to keep the entire surgical team informed. There were more oversights that culminated in error, which I'll discuss in detail at the conference. • Didn't you perform a time out? No. When the error occurred, hospital policy called for pre-op time outs, but the process wasn't standardized and safe- ty checks often occurred before the patient entered the OR. Now, time outs occur just before the incision is made, with every member of the surgical team in the room, paying attention and actively participating. Everyone is empowered and encouraged to speak up if something seems amiss. • On sharing his story. We need to be open and honest about the mistakes we make, and about how well the systems we have in place to protect patients actually work in practice. Discussing the breakdowns that lead to surgical errors is the only way to learn from what went wrong and make needed improvements. It shouldn't be about placing or deflecting blame. The sooner we realize that everyone will make mistakes at some point in their surgical careers, we can move away from holding people accountable to unrealistic expectations of being perfect. It'll take a culture change to build and champion a system that replaces blame and shame with a sincere desire to drill down to why errors hap- K I C K E R 1406_ORX_guide_Layout 1 5/29/14 3:23 PM Page 18