4. Focus on systems, not people. Reprimanding an employ-
ee who makes a mistake might address a single incident, but it won't
solve a systemic problem. That's why Ms. Calloway is a proponent of
Just Culture (osmag.net/J7nHdF), a framework for helping organiza-
tions achieve what she calls "balanced accountability."
Rather than a blanket approach, Just Culture recognizes the differ-
ences between human error (accidentally placing an unsterilized
instrument on a tray or inadvertently using a look-alike, sound-alike
drug, for example), at-risk behavior (taking shortcuts with disinfec-
tion protocols between cases) and reckless behavior (ignoring
required safety steps, such as moving forward with a surgery without
conducting a proper time out). Put another way, it's designed to help
healthcare providers learn from their mistakes — regardless of
whether those mistakes resulted in patient harm — not dole out pun-
ishments to the guilty. "It really doesn't matter what the outcome is;
you're looking to adjust the behavior," says Ms. Calloway.
5. Recast your priorities. Adopting a culture of safety will chal-
lenge the deeply engrained OR mindset centered on performance. "A
classic example is the temptation to skip correct site marking and
patient identification in the name of speed and efficiency," says Dr.
Berguer. "That's not a problem 99 times out of 100, but for that 100
th
time, it is going to be a problem — and it's going to be catastrophic."
Although any newly adopted measures might feel awkward and even
intrusive at first, they'll quickly become part of the routine, says Dr.
Berguer, much like putting on a seat belt when you first get into your
car.
6. Be flexible. Even the most airtight safety protocols will face
challenges. "Usually it's some hole we hadn't foreseen or a collection
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SURGICAL
ERRORS
