Surgical Errors
What object was left in the patient for the case study used in this presentation?
Forceps
How old was the man from the case study used?
28
Why is inadequate patient documentation dangerous?
Without a clear medical history for a patient it is more likely for a patient to take a medication that they are allergic to.
The most common cause of patient identification errors
Miscommunication or failure to verify patient identifiers
What tv show focuses on Plastic Surgery errors?
Botched
What is wrong site surgery?
When a patient is operated on the wrong part of their body. Most commonly the wrong arm or leg.
How many blood transfusion errors occur in the U.S. annually?
414
Who do these documentation errors affect?
The physicians providing care and the patients themselves.
This crucial step—often skipped when staff are rushed—involves verifying two identifiers like name and date of birth
Performing the two-identifier check (name and date of birth)?
This type of error occurs when someone clicks “Yes” on an electronic medical record pop-up they definitely did not read.
Electronic documentation error
How often do people wake up during surgery due to errors in anesthesia dosage?
2 people for every 1,000 cases
What is the most common reason for blood transfusion errors?
improper bedside and chart labelling for blood type.
How to limit documentation errors?
Taking clear notes during a patients visit and keeping all information in online data bases that the provider/hospital goes through.
These are wrist-worn tools that contain unique identifiers and must be scanned before administering medication.
Patient ID wristbands
This error is basically the healthcare version of sending a text to the wrong person—giving orders meant for one patient to another.
wrong-patient order entry error
How do we limit surgical errors?
Paying closer attention and following a step by step protocol before opperating
What blood type is the universal donor?
Epic/MyChart
This type of error occurs when a patient receives another patient’s lab results, medications, or treatments.
Patient misidentification error
This “Swiss” model describes how multiple system failures line up to cause an error.
the "Swiss Cheese" model
How many surgical errors happen annually in the U.S.
4,000
Why is AB+ blood the universal recipient?
The blood lacks the antibodies to attack foreign antigens
What should you (as a patient) do to ensure health records are correct and up to date?
Have an online/mobile account to access your charts through your Primary Care Provider.
This technology uses machine-readable codes to reduce human error in patient identification.
Barcode Scanning
What were all of our names :)
Jenna, Robert, Anna, and Leah!