Certain situations in health care are particularly prone to miscommunication. One example is during the stress of emergency situations, when a physician may be rapidly giving orders for medications, blood transfusions, or procedures to be initiated. A technique referred to as “call-outs” helps ensure that critical orders are received correctly. The person to whom the verbal order is directed repeats the order verbatim to acknowledge he or she has received it and will be responsible for carrying it out. Hearing this call-out assures the ordering physician that the order was received, who will be performing it, and allows an opportunity to correct the order if it was misheard. Similarly, telephone orders are well known to be sources of misinterpretation of physicians’ treatment intentions (22). Check-back is a technique to minimize errors in this medium. In a typical situation, a doctor calls a nurse to order a medication for a patient. Check-back has three components. First, the physician gives the medication order to the nurse. Second, the nurse repeats the order back to the physician, specifying medication name, dose, route, and timing of administration. Lastly, the physician confirms back to the nurse that the order was correctly received. A handoff of a patient from one physician to another is a third opportunity for miscommunication. This relay team approach to care is occurring more frequently in medical education as a result of residency work-hour restrictions (23). To minimize errors in this setting, it is wise to use a structured script for communicating critical clinical information. One such script from the TeamSTEPPS program is the mnemonic I PASS the BATON, which is essentially a checklist of clinical items to be related to the person assuming the care of the patient (Fig. 3.2) (19). The key point is that management handoffs should be a formal process that does not rely on memory to convey crucial information.
An important feature of team resource management is the ability of any team member to “stop the line”; that is to halt the process or procedure when they feel a risk to patient safety is present. One recommended technique is the “CUS” method. This acronym represents three possible sets of “code words” that any team member may articulate to indicate that the procedure must stop until the safety concern is addressed. The letters in the acronym stand for “I’m Concerned”; I’m Uncomfortable”; and “I have a Safety concern.” Another method is the “Two-Challenge Rule.” This indicates that when a team member has a safety concern he or she should bring it to the attention of the physician in charge of the procedure in question. If the concern is not acknowledged or adequately addressed, the team member should address it a second time. If the concern is still unanswered or uncorrected, the team member is then obligated to go up the chain of command to a supervisor or higher-ranking physician to have his or her concerns satisfied.
All of these techniques can contribute to a safer environment for patient care in the operating room, emergency department, and on patient ﬂoors. However, none of them can be very effective without practice. The use of drills and simulations to rehearse these techniques in mock emergency situations is well established in anesthesia training programs (24,25). The use of simulators to teach basic surgical techniques including laparoscopy and robotic surgery are becoming more common (26–28). Drills and rehearsals for emergency situations improve outcomes and enhance safety (29–31).
Infection Control Hospital-acquired infections are one of the most common causes of morbidity in hospitalized patients (32). Reducing the incidence of these infections, and preventing their spread to other patients, should be a top priority for all health care providers.
Surgical site infections result in an increased length of stay for surgical patients, with all the attendant associated risks and increased costs (33). While not preventable 100% of the time, their incidence can be significantly reduced. There are many operating room techniques available to accomplish this, and they should be used consistently (34). These include avoidance of shaving of the operative site, appropriate antimicrobial skin preparation, preoperative hand antisepsis, use and correct timing of administration of antibiotic prophylaxis, and observance of sterile technique.