| Human error in medicine: change in cardiac operating rooms through the FOCUS initiative. | |
| | |
MedLine Citation:
|
PMID: 21449238 Owner: NLM Status: In-Process |
Abstract/OtherAbstract:
|
Human error in medicine is a significant cause of patient mortality. While there has been increased attention to safety in medicine since the Institute of Medicine publication To Err is Human, the profession at large has not progressed to the same degree as other highly complex industries such as aviation and nuclear power. The Flawless Operative Cardiovascular Unified Systems initiative (FOCUS) is a multi-year study/intervention to learn about and to improve human error in cardiac surgery. FOCUS has developed into an ongoing re-focusing through prospective interventional research schemes designed to effect positive change for improved patient care in cardiac surgery. The program was developed in conjunction with the Johns Hopkins University Quality and Safety Research Group using an approach termed locating errors through network surveillance (LENS). The LENS process was undertaken at Johns Hopkins University and another five centers where three major areas were examined observationally: interactions (communication) between operating room cardiac team members, clinical performance of known quality and safety dependent processes, and ergonomics/safety or human-machine interfaces. While collected data is currently being analyzed, preliminary results reveal over 800 human errors noted in the 40 cases observed. The errors observed are being categorized and taxonomy of errors is being created. Categories used in the FOCUS analysis include: teamwork and communication, compliance with existing protocols, knowledge or supervision, vigilance or situational awareness, equipment failure/design, poor operating room design/ergonomics, handoffs and transport problems, lack of professionalism, and ambiguity of responsibility. FOCUS is an initiative to change practice driven by science. Interventions based upon the observations already underway include efforts to decrease infection, adoption of the aviation concept of the "sterile cockpit", briefing and debriefing, reduction of drug error, and peer-to-peer assessment. The first FOCUS data is sobering and shows tremendous possibility for improvement. |
| | |
Authors:
|
Bruce D Spiess |
Related Documents
:
|
21161338 - Statistical thinking and knowledge management for quality-driven design and manufacturi... 21457558 - Practices, patients and (im)perfect data - feasibility of a randomised controlled clini... 20723148 - A quality risk management model approach for cell therapy manufacturing. 20608418 - Managing risk through a global capital strategy. 21934318 - Western and chinese medicine in oncology and hematology. 21199078 - The cord academy for scholarship in education in emergency medicine. |
Publication Detail:
|
Type: Journal Article |
Journal Detail:
|
Title: The Journal of extra-corporeal technology Volume: 43 ISSN: 0022-1058 ISO Abbreviation: J Extra Corpor Technol Publication Date: 2011 Mar |
Date Detail:
|
Created Date: 2011-03-31 Completed Date: - Revised Date: - |
Medline Journal Info:
|
Nlm Unique ID: 0267637 Medline TA: J Extra Corpor Technol Country: United States |
Other Details:
|
Languages: eng Pagination: P33-8 Citation Subset: T |
Affiliation:
|
Anaesthesiology and Emergency Medicine, Virginia Commonwealth University Medical Center, Richmond, Virginia 23298-0662, USA. bdspiess@vcu.edu |
Export Citation:
|
APA/MLA Format Download EndNote Download BibTex |
| MeSH Terms | |
Descriptor/Qualifier:
|
|
From MEDLINE®/PubMed®, a database of the U.S. National Library of Medicine
Previous Document: Troubleshooting adult ECMO.
Next Document: To do or not to do?--How people make decisions.