7 4 • O U T PA T I E N T S U R G E R Y M A G A Z I N E • J A N U A R Y 2 0 1 7
When medical errors
happen, it's tempting to
jump to conclusions
about why or how they
happened — and
whether anything could
have been done to pre-
vent them.
That's one of the rea-
sons root-cause analysis is so important, says Kathy Wilson, RN,
MHA, VP of quality for AmSurg, whose duties include gathering
information and implementing corrective actions for about 250
ASCs nationwide. "Once you start doing a root-cause analysis —
drilling down into the why — quite often your preconceived ideas
turn out to be different than what actually occurred," she says.
"You have to dig in and talk to people at the centers who are
doing the work to get to all the contributing factors."
It may be easy to say something was the result of human error
or equipment failure, and leave it at that, but is that enough to
prevent a mistake from happening again?
"We just had a problem this week where it turned out that the
person who usually completes one of the safety checks on a
machine was out on medical leave, and no one assigned a person
to replace him," says Ms. Wilson.
But now, armed with that information, the center can enact a
policy to make sure all employees are covered in the event of an
unexpected absence. — Jim Burger
WHY DRILL DOWN?
Assumptions Often Turn Out Wrong
• NEVER AGAIN Caregivers are likely to be more receptive
after they make mistakes they thought could never happen.
SURGICAL
ERRORS
