Surgical Error Cases

[8 MIN READ]

We are all fallible. Despite their best efforts, physicians, nurses, other healthcare workers, and indeed all humans, make errors. It is an essential component of our being. It is widely accepted that a systems approach to error prevention can counteract this fallibility. Nonetheless, errors do occur. These failures can often be explained by the “Swiss Cheese Model” of error. Multiple processes are designed to prevent a type of error. Each individual process may be imperfect but used in combination one process will succeed where another may fail. Like the holes in Swiss cheese, when these imperfections are aligned and multiple processes fail, errors occur.

Below I present three cases from which we can gain perspective on how poor communication, systems errors, and cognitive bias contribute to surgical errors.

Source: Hubspot

Categories: Uncategorized

Tags: Triage