Archive September 2019 XX, No. 9

Safety: We Don't Need Another Checklist

It's time to address the elephant in the operating room: human error.

Todd Rosengart

Todd Rosengart, MD, FACS

BIO

INNER VOICE
Pamela Bevelhymer, RN, BSN, CNOR
INNER VOICE Surgical professionals must learn to trust their instincts and take personal responsibility for performing safe surgery.

The surgeon had signed the patient's left side and was about to begin surgery, but something didn't feel right to the medical student in the room. "Can we check that one more time?" he asked. "I believe the procedure is supposed to be performed on the other side." It was the right call. The team averted a wrong-sided surgery because the person who occupied the most junior rung on the OR ladder listened to his intuition and felt empowered to speak up.

That event came to light during one of our health system's weekly conferences, during which surgical team members gather to review adverse events and discuss what we could have done differently. Our research team engaged with those conferences in 3 hospitals over 6 months to collect and analyze information about 182 adverse events that occurred during 5,365 procedures. We discovered human error was involved in more than half (106) of them.

Errors linked to communication, teamwork and system protocols were lower than we expected, indicating team-based approaches such as safety checklists have been largely effective in preventing patient harm. But other human errors — lack of attention, recognition mistakes and confirmation bias — are unresolved issues in today's ORs that we need to address, especially when our findings are applied to known national statistics: If human error, as indicated by our study, accounts for half of the adverse events that occur in as many as 5% of the 17 million annual U.S. surgeries, efforts to improve the cognitive performance of surgical teams could prevent about 425,000 adverse events each year.

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