An observational analysis of surgical team compliance with perioperative safety practices after crew resource management training

Leming-Lee, Susie; Jackson, T. Vincent; Feistritzer, Nancye; Higgins, Michael S.

doi:10.1016/j.amjsurg.2007.04.012

Cited by 80 publications

(59 citation statements)

References 8 publications

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“…Strategies to help reduce this potential for harm need to be explored and can include techniques such as direct observational analyses and simulations. 47,48 By targeting these risk factors for harm in the NICU, our data suggest that a significant number of errors that occur in this clinical setting could be reduced. …”

Section: Discussionmentioning

confidence: 89%

NICU medication errors: identifying a risk profile for medication errors in the neonatal intensive care unit

et al. 2009

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Objective: To identify a risk profile for harmful medication errors in the neonatal intensive care unit (NICU).Study Design: A retrospective cross-sectional study on NICU medication error reports submitted to MEDMARX between 1 January 1999, and 31 December 2005. The Rao-Scott modified w 2 test was used for analysis.Result: 6749 NICU medication error reports were submitted by 163 health-care facilities. Administering errors accounted for approximately one half of errors, and human factors were the most frequently cited cause of error. Patient age was not associated with an increased likelihood of an error being harmful (P ¼ 0.11). Error reports involving Institute for Safe Medication Practices (ISMP) High-Alert Medications, occurring in the prescribing phase of medication processing, or involving equipment/ delivery device failures were more likely to be harmful (Pp0.05). Conclusion:Risk factors for harmful medication error reports include use of ISMP High-Alert Medications, the prescribing phase of the medication use process, and failure of equipment/delivery devices.

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Section: Discussionmentioning

confidence: 89%

NICU medication errors: identifying a risk profile for medication errors in the neonatal intensive care unit

et al. 2009

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“…Human factors (distractions), specifically, are usually presented with an overview, sometimes underestimating their influence in the event of errors 8,19,31 .…”

Section: Discussion Discussion Discussion Discussion Discussionmentioning

confidence: 99%

Interrupções e distrações na sala de cirurgia do trauma: entendendo a ameaça do erro humano

Pereira

Correia

et al. 2011

Rev. Col. Bras. Cir.

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OBJETIVO: Compreender o fator humano como ameaça à segurança do paciente vítima de trauma no centro cirúrgico, traduzindo para a sala de operação algumas regras importantes já aplicadas no campo da aviação. MÉTODOS: A amostra incluiu 50 casos de cirurgia de trauma coletados prospectivamente por observadores em plantões de 12 horas, ,durante seis meses, em um centro de trauma nível I nos Estados Unidos da América. Informações quanto ao tipo de trauma, escore de gravidade e mortalidade foram coletadas, assim como, determinantes de distrações/interrupções e o volume de ruídos na sala de cirurgia durante o ato cirúrgico. RESULTADOS: Ocorreram, em média, 60 interrupções ou distrações durante o ato cirúrgico, na maioria das vezes desencadeado pelo movimento de pessoas na sala. Em pacientes mais graves (ISS > 45), submetidos ao controle de danos, a incidência de distrações foi ainda maior. A média de ruídos na sala de cirurgia do trauma foi muito elevada, com barulho próximo ao de um secador de cabelos. CONCLUSÃO: Interrupções e distrações são frequentes e devem ser estudadas pelo cirurgião do trauma a fim de desenvolver estratégias de prevenção e linhas de defesa para minimizá-las e reduzir seus efeitos.

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“…It has been commonly assumed that most of the barriers to "effective implementation," such as negative attitudes, operate at the level of the individual health care professional (Grimshaw, Eccles, & Tetroe, 2004). An observational study by France, Leming-Lee, Jackson, Feistritzer, and Higgins (2008) on the compliance to a surgical team checklist, for example, focused on the "engagement" of individual professionals. Although we argue that individual attitudes do matter, from our analysis, we claim that they only exist, change-and thus matter, in interaction with others.…”

Section: Discussionmentioning

confidence: 99%

Connective Routines: How Medical Professionals Work with Safety Checklists

Kuiper¹

2018

P&P

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New standards like checklists are introduced to establish so-called "connective professionalism," but it is difficult to work with checklists in daily circumstances. Professionals might comply with standards, but they might also neglect or resist them. By linking the sociology of professions to routine theory, we develop a relational perspective on working with standards, which is sensitive to the actual usage of standards, not so much "by" but "in-between" professionals. We analysed whether and how checklists are part of daily professional routines. Our ethnographic data show that medical professionals pragmatically cope with checklists. They "tick boxes," but also use standards to improve case treatment, depending on the nature of cases, time pressure, and team composition. Connections between professionals not so much result from standards, but are a prerequisite for using standards. Professionals themselves rather than checklists establish collaboration, but checklists might be important devices for using "connective potential." Keywords: Professional work, surgery, standards, implementation, routines, copingThe past few decades, many scholars have emphasized that routines are crucial for how organizations accomplish their tasks (Cyert & March, 1963; Nelson & Winter, 1982). Routines are "recognizable, repetitive patterns of interdependent action carried out by multiple actors" that structure work and are a basic necessity to carry out complex work in organizations (Feldman, Pentland, D'Adderio, & Lazaric, 2016, p. 505;Feldman & Pentland, 2003;Novak et al., 2012). Routines were mostly associated with stability and inertia (Cyert & March, 1963; Nelson & Winter, 1982) but a more recent perspective in the literature explicitly focuses on routines as a source for coping with complexity and change (e.g., Becker et al., 2005, Feldman & Pentland, 2003Feldman et al., 2016;Parmigiani & Howard-Grenville, 2011).Building on this, studies paid explicit attention to how organizational routines are changed triggered by exogenous events (Nigam, Huising, & Golden, 2016). Fundamental transitions in the context of work, such as new governmental regulations, knowledge and technologies, client demands and budgetary restraint (for an overview see Noordegraaf, 2015;2016) explicitly affect work in professional service domains and urge professionals to adapt their ways of working.More specifically, the complex interplay of service pressures has made professional service delivery more multifaceted, and this calls for multi-professional action (Noordegraaf, 2011;2016 healthcare require cooperation between various professionals. They might come from different (sub)disciplines. Professionals need to find ways to organize collaboration and create new routines that are connective (Noordegraaf, 2016;Noordegraaf, Schneider, van Rensen, & Boselie, 2016;Noordegraaf, van der Steen, & van Twist 2014). Put differently, the "recognizable, repetitive patterns of interdependent action carried out by multiple actors" need to be reconfigu...

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An observational analysis of surgical team compliance with perioperative safety practices after crew resource management training

Cited by 80 publications

References 8 publications

NICU medication errors: identifying a risk profile for medication errors in the neonatal intensive care unit

NICU medication errors: identifying a risk profile for medication errors in the neonatal intensive care unit

Interrupções e distrações na sala de cirurgia do trauma: entendendo a ameaça do erro humano

Connective Routines: How Medical Professionals Work with Safety Checklists

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