Patient Safety and Communication in the Operating Room

operating room procedure;culture of safety;Team STEPPS;error management;operating room teamwork;Swiss cheese model;Anesthesia;surgery;Doctor of Anesthesia Practice

Owens, DerekFockler, Thomas U. ;

University of Michigan

关键词: operating room procedure;    culture of safety;    Team STEPPS;    error management;    operating room teamwork;    Swiss cheese model;    Anesthesia;    surgery;    Doctor of Anesthesia Practice;   

Others  :  https://deepblue.lib.umich.edu/bitstream/handle/2027.42/136781/Owens2015.pdf?sequence=1&isAllowed=y

瑞士|英语

来源: The Illinois Digital Environment for Access to Learning and Scholarship

【 摘 要 】

Hospitals, and in particular the operating room, have not universally adopted a checklist system as a way to increase communications and decrease errors. Analyses showed that communication at Navy Hospital Twenty-nine Palms was less than optimal, leading to errors, such as delayed surgical start times and equipment errors, although patient safety was not affected. After thorough research, including a comprehensive literature review, and investigation by the author and operating room director, it was decided that the World Health Organization/The Joint Commission comprehensive surgical checklist and the Team STEPPS communication technique would be adapted and implemented to increase communication. Implementation of these programs would undergo evaluation through monitoring and staff interviews on a continual basis by committee members and process adjustments if needed after committee member agreement. This checklist would flatten the hierarchy and improve the operating room process, increasing patient safety. This checklist to increase communication in the operating room is not expected to prevent all errors but could increase safety by creating a shared mental model and increased distribution of responsibility to all health care personnel involved. By empowering every team member, from technicians to surgeons, the ability to raise concerns raises the standards for patient safety.