PREVENTION OF SURGICAL ERRORS

Course overview

A SURGICAL ERROR IS AN UNINTENTIONAL, PREVENTABLE INJURY OCCURRING IN THE PERIOPERATIVE PERIOD THAT IS NOT CONSIDERED A KNOWN ACCEPTABLE RISK OF SURGERY AND COULD HAVE BEEN AVOIDED BY FOLLOWING APPROPRIATE PROCEDURE-SPECIFIC TRAINING PROTOCOLS. SURGICAL ERRORS ARE A TYPE OF MEDICAL ERROR AND INCLUDE RETAINED FOREIGN BODIES, MISLABELED SURGICAL SPECIMENS, AND WRONG-SITE, WRONG-PROCEDURE, AND WRONG-PATIENT ERRORS (WSPES). AN ANALYSIS OF THESE ERRORS OVER THE LAST FEW DECADES HAS REVEALED THEIR CAUSE IS OFTEN MULTIFACTORIAL. HOWEVER, MISCOMMUNICATION, UNNECESSARY OR EMERGENT PROCEDURES, INSUFFICIENT TRAINING, AND PROVIDER BURNOUT REPRESENT COMMON CAUSES OF SURGICAL ERROR. SURGICAL ERRORS CAN BE POTENTIALLY CATASTROPHIC, CARRY A SIGNIFICANT FINANCIAL BURDEN, AND ARE LIKELY UNDER-REPORTED. SEVERAL ORGANIZATIONS HAVE DEVELOPED STRATEGIES TO DETERMINE WHY THESE ERRORS OCCUR AND HOW TO MITIGATE THE INCIDENCE. THE JOINT COMMISSION IS ONE EXAMPLE OF AN ORGANIZATION THAT HAS DEVELOPED A UNIVERSAL PROTOCOL TO HELP MONITOR AND DECREASE SURGICAL ERRORS. THIS ACTIVITY REVIEWS SURGICAL ERRORS AND EFFECTIVE INTERPROFESSIONAL TEAM APPROACHES TO CREATE A CULTURE OF SAFETY THAT STRIVES TO REDUCE SURGICAL ERRORS AND IMPROVE PATIENT OUTCOMES.