Outpatient Surgery Magazine

Manager's Guide to Staff & Patient Safety - October 2015

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/579475

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Page 80 of 80

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

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