Improving Operating Room and Perioperative Safety: Background and Specific Recommendations
The 1999 Institute of Medicine report To Err Is Human put a spotlight on death from preventable medical errors. Surgically related errors are second only to medication errors as the most frequent cause of error-related death. Although many hospitals have ongoing programs to improve medication safety, most hospitals are not focused in a meaningful way on operating room (OR) safety despite the import of the OR to the hospital's finances and despite clearly efficacious available technologies.
The perioperative environment is a high-risk area with high velocity, high complexity, and high stakes. OR errors lead to disproportionately more harm than errors elsewhere in the hospital. Actual adverse events are relatively rare in any given OR suite, but near misses are rather common. It is possible to learn much from evaluating near misses (along with adverse events) with root-cause analyses and then instituting changes in processes and systems to assist humans from making their inevitable errors. This article outlines approaches that when combined can markedly improve safety in the OR.
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Although many hospitals have ongoing programs to improve medication safety, most hospitals are not focused in a meaningful way on operating room (OR) safety despite the import of the OR to the hospital's finances and despite clearly efficacious available technologies.
The perioperative environment is a high-risk area with high velocity, high complexity, and high stakes. OR errors lead to disproportionately more harm than errors elsewhere in the hospital. Actual adverse events are relatively rare in any given OR suite, but near misses are rather common.
It is possible to learn much from evaluating near misses (along with adverse events) with root-cause analyses and then instituting changes in processes and systems to assist humans from making their inevitable errors. This article outlines approaches that when combined can markedly improve safety in the OR.
The list of what can go wrong during surgery is long and intimidating. Retained foreign bodies, wrong site surgery, mislabeled pathology specimens, operative fires, and transfusion and medication errors are only some of the preventable hazards associated with surgery. Adverse events occur more often in surgical patients than in those of any other clinical specialty, and disproportionately greater harm results from surgical errors.
Moreover, patients are most vulnerable when they are having surgery. Advice to patients to become their own safety advocates is difficult to follow when they are anesthetized or drowsy from pain medication. No alert and watchful family members hover at the bedside to correct mistaken information or remind caregivers of important facts that may be overlooked.
Patients and families place their trust in perioperative nurses and their surgical colleagues to ensure that the patient receives safe and effective care.
I absolutely LOVE this! Masterfully written.
Nursing Letter of Recommendation
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