From box ticking to the black box: the evolution of operating room safety
- PMID: 31363833
- DOI: 10.1007/s00345-019-02886-5
From box ticking to the black box: the evolution of operating room safety
Abstract
Purpose: Efforts to improve the safety of patients in the operating room have focused on mitigating harm through the standardization of system, team, and human level factors. This article highlights existing and future methods for enhancing safety in the perioperative setting, and the theory and principles that underpin them.
Methods: Evidence surrounding the development and implementation of select surgical safety interventions is discussed.
Results: Work in human factors and engineering that has inspired safety interventions such as the WHO Safety Checklist, and more recently operating room recorders, represents a movement away from traditional, retrospective or reactive methods of studying surgical safety, to prospective and proactive ones.
Conclusions: Future work will examine the effectiveness of these interventions for improving patient outcomes and minimizing iatrogenic harm.
Keywords: Black box; Checklist; Patient safety.
References
-
- Bilimoria KY, Kmiecik TE, DaRosa DA et al (2009) Development of an online morbidity, mortality, and near-miss reporting system to identify patterns of adverse events in surgical patients. Arch Surg 144(4):305–311. https://doi.org/10.1001/archsurg.2009.5 - DOI - PubMed
-
- Hempel S, Maggard-Gibbons M, Nguyen DK et al (2015) Wrong-site surgery, retained surgical items, and surgical fires: a systematic review of surgical never events. JAMA Surg 150(8):796–805. https://doi.org/10.1001/jamasurg.2015.0301 - DOI - PubMed
-
- Seiden SC, Barach P (2006) Wrong-side/wrong-site, wrong-procedure, and wrong-patient adverse events: are they preventable? Arch Surg 141(9):931–939. https://doi.org/10.1001/archsurg.141.9.931 - DOI - PubMed
-
- Baker GR, Norton PG, Flintoft V et al (2004) The Canadian adverse events study: the incidence of adverse events among hospital patients in Canada. Can Med Assoc J 170(11):1678–1686. https://doi.org/10.1053/cmaj.1040498 - DOI
-
- Brennan TA, Leape LL, Laird NM et al (1991) Incidence of adverse events and negligence in hospitalized patients. Results of the Harvard medical practice study I. N Engl J Med. 324(6):370–376. https://doi.org/10.1056/nejm199102073240604 - DOI - PubMed
MeSH terms
LinkOut - more resources
Full Text Sources
Medical
