Tuesday, March 29, 2016

"Preoccupation with Failure"

           Working in any Operating Room presents us with multiple potential opportunities for system failure on a daily basis. Failure to monitor and track "single event" problems will eventually accumulate and likely result in a complete systematic shutdown. At that point, someone will speak up and say "oh, that---- has been an issue for months". The Pediatric Cardiac Surgery Unit at Washington University St Louis recently published the results of their study (J Am Coll Surg Jan 2015) looking at ALL problems (big or small) occurring in the OR's during the course of the study. It was clear, eventually, how many small problems existed that were simply not tended to because everyone was simply overwhelmed with their daily workload to report or deal with these issues. Kudos to the one surgeon who decided to do something about that!! Unlike flying a plane, we simply do not have an electronic "black box" to tell us all the issues that lead to a disaster and we have to resort to more cumbersome techniques to detect these "minor" issues and track and trend their results and eventual correction. To top it off, the team proved what has been said for years about our field: "videotaping the OR environment revealed how often individuals were not paying attention, despite their impression otherwise." This attitude appeared to have occurred during critical event phases as well. Simple changes such as eliminating all distractions during these critical phases were rapidly implemented. While we certainly cannot prevent unanticipated events from developing in our institution, we can detect the multitude of potential nuisance issues from collecting in the drain trap. If left undetected or unresolved, these small problems will eventually clog the system so that when that one final unanticipated event occurs, we are unable to mitigate the event and succeed.
If we do not preoccupy the institution with all the "what if's" that could eventually accumulate to create a failure, we will fail.

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