文档介绍：What’s New in Safety in the OR?
Keith P. Lewis, ., MD
Professor and Chairman
Department of Anesthesiology
Boston University School of Medicine
August 14, 2014
7:00 – 8:00 AM
Boston Medical Center 2014
Boston University
School of Medicine
East Newton
Pavilion
Menino Pavilion
Shapiro Building
Moakley Building
Lucian Leape, MD
Everyone makes errors everyday
No one makes an error on purpose
An error is not misconduct
We make errors for a reason
Why Do Errors Occur?
Interruptions
Fatigue
Multi-tasking
Failure to follow-up
Poor hand-offs (hand-overs)
munication
Workload fluctuations
Harvard Closed Claims Review
Ten years of closed OB claims from Harvard hospitals
2-3 reviewers
Structured review form
Consensus required
mon team-related deficiencies
Failure to cross-monitor: 76%
munication: 67%
42% of cases could have been prevented or mitigated with better teamwork
Surgery-Related Cases
Technical skills: Injuries sustained during surgery from technical errors (including laparoscopic procedures)
Inadequate review – Improper clearance for surgery
Lack of reliable processes to ensure correct site identification
Lack of teamwork in the operating room (OR . communication among providers plications
Lack of information – OR to post anesthesia care unit
Poor post operative management
Crico Risk Management Data
Obstetric-Related Cases
Inadequate management of second stage of labor
Failure municate worrisome signs
Failure to respond to concerns being raised by other providers
Incorrect interpretation of clinical data (. electronic fetal monitoring strips)
Technical skills: poor management of dystocia
Failure to identify prenatal risk factors
Problems encountered in “managing the unexpected”
Low risk to high risk – a failure by the provider to appreciate the patient’s change in clinical status

Crico Risk Management Data
Recognition, management, and prevention
of specific
operating room catastrophes
Presented at the American College of Surgeons