A human unsupported by automated checks filled out an inaccurate
consent form that Dr. Berry signed without a second thought. How
many times do you think that scene plays out in surgeons' clinics
across the country? "I was really nervous — and I'm a surgeon and
patient safety expert," says Dr. Berry. "If anybody could have armed
themselves against an error in care, it should have been me."
But he didn't. If his wife hadn't intervened, the inaccurate consent
form might have made it into the OR the next day. "And the double
checks that every surgical team is asked to perform wouldn't have
caught the mistake," points out Dr. Berry. "A time out would have rein-
forced the wrong site. The potential for harm was generated in the clin-
ic."
Dr. Berry spent 10 years of his career reviewing malpractice cases,
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Viscot Communication Boards
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Visibility to improve patient & staff safety
61% of sentinel events are caused by communication failures*
*The Joint Commission
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SURGICAL
ERRORS
