OR Manager - June 2019 - 14
SPECIAL SERIES
Continued from page 13
Catherine
Hogan, PhD,
RN
Multiple conversations
result in people becoming
distractors instead
of enablers. " We will
ask people to leave the
theater if they aren't
ne c essa r y , "
sa y s
Hogan, who adds that
she validates findings
from the OR Black Box
with staff. For instance, staff agreed
that the number of people in the OR
was often too high.
Hogan says an important value of
the OR Black Box is that it's research
based. " We have data to back up our
recommendations, " she says. Those
recommendations can be as simple as
lowering the volume of music played in
the OR based on auditory analysis of
data from the OR Black Box.
Dr Grantcharov adds that the OR
Black Box allows perioperative teams to
quantify not only safety threats but also
resilience supports (factors that allow
systems and teams to be successful despite
conditions that can lead to failure)
using the Systems Engineering Initiative
for Patient Safety Model. (This model is
described at https://www.ncbi.nlm.nih.
gov/pmc/articles/PMC2464868/.)
The research team at St Michael's
Hospital in Toronto and The Academic
Medical Centre in Amsterdam use packaged
video reports of the events as part
of safety discussion during a debriefing
of the surgical team. The debriefings
have prompted positive practice
changes.
Culture change
Successful implementation of the
OR Black Box depends on having the
right organizational culture. " With the
OR Black Box, we don't only focus on
things that go wrong, " Dr Grantcharov
says. " We also want to capture
things that we do exceptionally well. "
He notes that clinicians often achieve
good patient outcomes even when an
adverse event occurs, and there are
lessons to be learned from that.
" We want to change the way hospitals
usually address quality improvement, "
Dr Grantcharov says. Too often, action is
taken only after an adverse event, which,
he says, creates a natural resistance.
" People believe that quality and safety is
a bad thing because the only time they
talk to quality and safety people is when
they make a mistake, " he notes.
A better approach is to use OR Black
Box data to reinforce positive behaviors
and examine processes that near
misses have indicated need to be evaluated.
In addition, the entire process
should be transparent.
ONE
Patient
ONE
Surface™
From admission to discharge
Learn more at wincomfg.com/TMM-Series
or call 352.854.2929
ENHANCING THE PATIENT
AND CAREGIVER EXPERIENCE
14
OR Manager | June 2019
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OR Manager - June 2019
Table of Contents for the Digital Edition of OR Manager - June 2019
OR Manager - June 2019 - 1
OR Manager - June 2019 - 2
OR Manager - June 2019 - 3
OR Manager - June 2019 - 4
OR Manager - June 2019 - 5
OR Manager - June 2019 - 6
OR Manager - June 2019 - 7
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