This is a better preventive strategy than a personal approach that focuses on training the concerned personnel to recheck the type of agent before filling).Įrror prevention should target the cause. (e.g., Noninterchangeable filling ports eliminate the possibility of filling the vaporizer with a wrong volatile agent. Hence, the emphasis has now shifted towards “system approach” wherein the focus is on introducing practices that make the entire system error resistant. As enumerated in Table 1, errors are multifactorial and even a competent individual can commit an error in certain scenarios. This approach is flawed because errors are not always due to incompetence. Traditionally, errors were attributed to the incompetence of individuals, and emphasis was laid on individual training (personal approach of error prevention). Violation is intentional and occurs due to a lack of safety culture and motivational issues at the individual level. Deliberately omitting anesthesia machine check due to turnover pressure is a violation. If the deviation from safe practice is intentional, it is termed “violation.” (e.g. Keeping track of near-misses gives insight into loopholes in the system and helps in designing multiple checkpoints to prevent the catastrophe. ‘Near-miss” is defined as “an error that has the potential to cause an adverse event (patient harm) but fails to do so because of chance or because it is intercepted.” In simple terms, near-miss is a close call that could easily have resulted in patient harm but luckily did not. According to Reason's Swiss Cheese model of system accidents, multiple errors can cause the holes in layers of “Swiss cheese” to align resulting in a major catastrophe. Full-text articles published until December 2018 were included.ĭefining Error, Near Miss, and Violation in HealthcareĮrror is an unintentional deviation from safe practice. An electronic search was performed on Google Scholar and PubMed for original and review articles using keywords “patient safety in OR,” “human errors,” “cognitive errors,” “medication errors,” “cognitive aids,” and “perioperative safety” until December 2018. In this descriptive review, common errors in the operating room (OR), their causative factors, and preventive strategies to enhance patient safety will be discussed. The article attempts to address the issue of patient safety in operating rooms. Most of the data related to error management are from western countries. An Indian survey of anesthesiologist's shows that undesirable practices are common and can have implications for patient safety. Sad as it may seem, there is a lack of awareness about the ways and means of error prevention among clinicians, especially in developing countries. Many of the safety and quality improvement practices in anesthesiology have been adopted from the aviation industry. Hence, they serve as excellent models for the error-resilient system. HROs are organizations working in hazardous conditions under enormous pressure yet have very low or nil catastrophe rates. Human factors in the context of error causation are extensively studied and preventive strategies have been adopted in healthcare from high-reliability organizations (HROs) such as the aviation industry and nuclear power stations. Since then, healthcare fraternity has been trying to focus on error prevention. About 4–17% of hospital admissions are associated with adverse medical events and nearly two-thirds are preventable.Ī report titled “To err is human: building a safer health system” was the pioneer report which alerted the medical community towards errors in healthcare. It is still estimated to be the third leading cause of death in the US if it were counted as a disease. Medical errors were reported to be responsible for up to 98,000 deaths and 1 million injuries each year in the United States in 1999. Despite being manned and run by qualified personnel dedicated to patient safety, the healthcare sector is not immune to error. Patient safety is the primary motto of the healthcare delivery system.
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