of circumstances that occurred, so we'll do a root cause analysis and
might have to go back and amend the protocol," says Dr. Berguer.
This reminds him of a consulting surgeon who came to the OR to
assist with a complex case. Although the house surgeon fully under-
stood the nature of the surgery, the consulting surgeon had prepared
for a different operation on a different patient. The facility has since
adopted a 3-step process designed to avoid such near misses:
• a sign in to confirm patient, procedure and consent, among other
things, prior to induction;
• a time out just before incision; and
• a sign out after the incision has been closed to confirm patient
name and procedure, instrument count, and review of anticipated
recovery issues and equipment problems.
OSM
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