Protecting patients from an unsafe system

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• 作者：Yue-Yung Hu ; MD ; MPH ; Alexander Arriaga ; MD ; MPH ; Emilie M. Roth ; PhD ; Sarah E. Peyre ; EdD ; Richard S. Swanson ; MD ; FACS ; Robert T. Osteen ; MD ; FACS ; Pamela Schmitt ; RN ; Angela M. Bader ; MD ; Michael J. Zinner ; MD ; FACS ; Caprice C. Greenberg ; MD ; MPH ; FACS
• 刊名：Journal of the American College of Surgeons
• 出版年：2011
• 出版时间：September, 2011
• 年：2011
• 卷：213
• 期：3_supp_S
• 页码：S111
• 全文大小：1K

文摘

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Introduction

Surgical teams must deal regularly with unanticipated events in the operating room (OR). We sought to understand the etiology and resolution of these events using a qualitative assessment.

Methods

To increase the likelihood of capturing an event, we video-recorded and transcribed 8 complex, high-acuity operations, representing 36 hours of patient care. Deviations, defined as episodes of decreased patient safety and/or delays, were identified by majority consensus of a multidisciplinary team. Factors that contributed to each event and/or mitigated its impact were determined and attributed to the system, team or individual provider.

Results

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	Contributing Factors	% of Deviations	Mitigating Factors	% of Deviations
Individual Provider	(Lack of) Knowledge/Training	25	Monitoring/Vigilance	63
	(Lack of) Leadership	17	Knowledge/Training	17
			Decision-Making	17
			Leadership	38
Team	(Mis)Communication	33	Communication	50
	(Mis)Coordination	46	Coordination	33
			Cooperation	33
System	Equipment (Failure)	17	-	-
	Organizational Structure	29