O C T O B E R 2 0 1 5 O U T P A T I E N TS U R G E R Y. N E T 8 1
"Never events" continue to happen. Why?
Sadly, though we try, it's hard to get to zero bad events. That doesn't mean we
can't do better. Too often the lessons we've borrowed from safe industries
have been superficial and siloed. Surgery borrowed teamwork training from
aviation, but unlike pilots, who have to pass a competency in teamwork to fly,
surgeons and nurses can work in the OR with no such training. We took the
concept, but didn't follow through on the execution.
Can improvement to surgical technology also improve patient safety?
It should. But safety is largely based on the heroism of clinicians rather than
the design of safe systems. Vendors often develop technology with very little
clinical input and tell doctors and nurses to use it. Other industries do a bet-
ter job of co-developing technologies with users, so the tools serve their
needs.
What can OR teams learn from near-misses and adverse events?
Clinical teams are great at recovering from mistakes, but poor at learning from
them. They don't have the time or ability to pause and reflect on what drove
the error and design systems that prevent it from happening again. Production
pressure prevents that from happening. Blame and fear certainly do, too. We
can't work in a culture that doesn't allow mistakes to be openly discussed and
addressed. OSM
