2 7
J U N E 2 0 1 4 | 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
• Layers of vulnera-
bilities. As I worked
with hospital employees
and physicians to resolve
claims and lawsuits, it
became apparent that
medical errors could
rarely be attributed to a
single person. Instead,
there was usually a con-
vergence of multiple
process or system fail-
ures that ultimately cul-
minated in the error.
Reviewing closed claims
and lawsuits created an
opportunity to peel back
the layers and identify
the vulnerabilities that
contribute to adverse
outcomes.
• Common causes
of errors. Despite
improved technology
with monitoring equip-
ment, many adverse
patient outcomes can be
traced back to inade-
quate or absent monitor-
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