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/685863
3 4 S U P P L E M E N T T O O U T P A T I E N T S U R G E R Y M A G A Z I N E J U N E 2 0 1 6 J an Kleinhesselink, RN, CPHQ, and Carmen Lester, RN, JD, work down the hall from each other at the Lincoln (Neb.) Surgical Hospital, where part of their responsibilities involves investigating why adverse events occur and what can be done to prevent them from hap- pening again. In their ORX presentation "True Detective: Uncovering the Real Root Cause," the always-entertaining duo will discuss how medical errors aren't always what they appear to be and how uncovering the actual factors that lead to mistakes demands shifting away from a nar- row focus on the obvious issues. • Drilling down is difficult. As leaders, you have the best intentions in trying to determine how to fix a prob- lem. But you sometimes determine "the fix" using your own biases, perspectives, experiences and agendas, which can lead you to formulate the solution to a problem before ever taking the time to drill down to the exact causes. Or maybe a time constraint becomes a factor in the analysis, so you determine the solution first — instead of last — and work backward to justify that your solution is the cor- rect fix. • Avoid the narrow perspective. You can't solve a prob- lem by only looking at a brief snapshot in time. The image you're looking at is only a small portion of the larger picture. It's easy to fall into the pattern of making a knee-jerk decision Uncovering the Real Root Cause of Mistakes It takes good detective work to get to the bottom of adverse events. • Chief clinical officer of Lincoln (Neb.) Surgical Hospital. • Received law degree from the University of Nebraska College of Law. • Member of American Organization of Nurse Executives and the American College of Healthcare Executives. Carmen Lester, RN, JD Speaker Profile • Chief quality officer at Lincoln (Neb.) Surgical Hospital. • AAAHC surveyor. • Has been in surgical leadership roles for more than 25 years. Jan Kleinhesselink, RN, CPHQ Speaker Profile