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Reducing Surgical Errors: Implementing a Three‐Hinge Approach to Success
Author(s) -
Landers Ronda
Publication year - 2015
Publication title -
aorn journal
Language(s) - English
Resource type - Journals
SCImago Journal Rank - 0.222
H-Index - 43
eISSN - 1878-0369
pISSN - 0001-2092
DOI - 10.1016/j.aorn.2015.04.013
Subject(s) - checklist , group cohesiveness , staffing , medicaid , ambulatory , medicine , patient safety , nursing , medical emergency , psychology , surgery , health care , social psychology , economics , cognitive psychology , economic growth
Surgical errors can have serious consequences including patient deaths, and recent reports suggest that surgical errors continue to occur at unacceptable rates. Studies indicate that causative factors for surgical error include human factors, OR interruptions, staffing issues, and error‐reporting trends. A “three‐hinge” approach can be used to implement a safety program that emphasizes use of a safe surgery checklist and the Centers for Medicare & Medicaid Services reporting requirements for ambulatory surgery centers. The three hinges are the assignment of a change agent, ideally an RN with a doctorate in nursing practice; team cohesiveness; and continuous quality monitoring.