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 2 5
One explanation for this is that healthcare professionals have a tendency to
be optimistic. We expect the surgery to go smoothly, with no errors or harm to
the patient. There's a "preoccupation with failure" in other safe organizations
or industries. In aviation, for example, pilots are constantly looking for what
could go wrong and working to prevent it before it happens, which increases
overall safety.
Stress to staff and physicians that instead of assuming things are always right
for every case, they should assume things will go wrong and make an effort to
prove things are correct. For example, the discussion during a time out
shouldn't be "We're operating on the left knee." Instead, the surgical team
should say, "We're operating on the left knee because the original documenta-
tion shows us that, and the patient herself agreed in pre-op."
5. Changing the culture isn't impossible
Researchers who studied incidents of wrong-site surgery cases found that 90%
of the time someone felt like something was wrong during the case, but didn't
speak up. Usually it's because they were afraid of being embarrassed. Or worse,
staff did speak up, but were ultimately ignored. Harming a patient is a high price
to pay for poor teamwork and communication.
Everyone in the OR must be encouraged to speak up if they see something
wrong. Your surgeons are the ones who inspire this culture in the OR. Typically,
though, that's easier said than done. The key thing to remember is that surgeons
are drawn to logic and reasoning.
When I talk to doctors about enhancing teamwork, I discuss the science behind
why teams make good decisions. While a surgeon may think that years of training
or education is the foundation of wise decisions, research has discovered 2 dis-
tinct attributes that enhance a team's overall decision-making.
The first is that they welcome and embrace diverse and independent input.
In your facility, that translates to nurses, techs or even schedulers sharing
