NerdeNurse

I agree. The only reason I used the foley as an example was that it was specifically mentioned as a distraction in the actual study.

J. Adderton, you summed it up well. I enjoyed your article, so I went to the full study article. I was disappointed in the actual study for four main reasons. 1. The authors of the study wrote, “Our study is potentially limited in that our HPD adjudication method does not provide absolute certainty as to the primary cause of adverse events, in part because it relies on self-reporting, which in turn must occur in a just culture” and “It must also be recognized that this study was performed in an academic medical setting and involved a heterogeneous sample of surgical operations that may not be applicable to other institutions with different cultures and case mixes”. 2. Out of the 188 cases, 6 were nonsurgical? 3. To me, it seemed that the study was too broad. I may have missed it but I wished I could have seen the tool used for collecting the data. 4. Did study only review doctors or were other disciplines included? I would like to have seen a breakdown by profession/role because the two specific examples they wrote about were a radiologist and a surgeon. I was impressed for a couple of reasons: 1. That they were using real-time data and not just doing chart reviews. 2. In the conclusion, they said, “These data suggest that an opportunity exists to develop simulation-based cognitive training of health care practitioners and teams to reinforce systems-based safety constructs, which alone were unable to prevent many adverse events in our study.19,37,38 As an example of such training, exercises could involve simulated playbacks of real-life scenarios taken from our situation, background, assessment, and recommendation anthology, similar to training performed in the aviation and aerospace industries”. I found the following detailed in the study: Adverse Events Associated with Human Performance Deficiency: Hospital A = 58.3% (35 out of 60 events) Hospital B = 61.1% (55 out of 90 events) Hospital C = 42.1% (16 out of 38 events) Service: Acute Care or Trauma = 58.8% (50 out of 85 events) Cardiothoracic = 33.3% (4 out of 12 events) Surgical Critical Care = 50% (5 out of 10 events) General, Colorectal, or Bariatric = 62.5% (5 out of 8 events) Surgical Oncology = 56.6 % (30 out of 53 events) Transplant = 60% (6 out of 10 events) Vascular = 60% (6 out of 10 events) The reason this information piqued my interest is: 1. What is hospital C doing better than hospitals A and B? 2. What is Cardiothoracic and Critical Care doing better than the others? It would be interesting to see the profession/role breakdown and if there were repeat offenders. I have worked in Pre-Op and PACU and have seen what a high-pressure process surgery is from beginning to end. Some errors are system driven and some are physician-driven. I think the role breakdown would give greater definition to this type of study. Presenting site-specific, real-life scenarios on a regular basis is a great tool for education and improving compliance. I think that, when presenting the scenarios, each profession/role needs to be present as a team. I have also seen pre-op team meetings increase the cohesiveness of the surgical team. Both of these help team building and identifying potential problems before going into the OR suite. For instance, if there is a possibility that the patient needs to have a foley during surgery, maybe the foley should be placed before going back to the surgical suite.