Surgical debriefing: a reliable roadmap to completing the patient safety cycle

被引:20
|
作者
Zuckerman, Scott L. [1 ]
France, Daniel J. [2 ]
Green, Cain [5 ]
Leming-Lee, Susie [3 ]
Anders, Shilo [4 ]
Mocco, J. [1 ]
机构
[1] Vanderbilt Univ, Dept Neurol Surg, Sch Med, Nashville, TN 37232 USA
[2] Vanderbilt Univ, Dept Anesthesiol, Sch Med, Nashville, TN 37232 USA
[3] Vanderbilt Univ, Dept Perioperat Serv, Sch Med, Nashville, TN 37232 USA
[4] Vanderbilt Univ, Ctr Res & Innovat Syst Safety, Sch Med, Nashville, TN 37232 USA
[5] Univ Tennessee, Ctr Hlth Sci, Coll Med, Memphis, TN 38163 USA
关键词
neurosurgery; checklist; adverse event; preventable error; debriefing; time-out; OPERATING-ROOM BRIEFINGS; POSTOPERATIVE DEBRIEFINGS; SUCCESSFUL IMPLEMENTATION; PREOPERATIVE BRIEFINGS; TEAM COMPLIANCE; ADVERSE EVENTS; PERFORMANCE; SIMULATION; IMPACT;
D O I
10.3171/2012.8.FOCUS12248
中图分类号
R74 [神经病学与精神病学];
学科分类号
摘要
Morbidity and mortality due to preventable medical errors are a disastrous reality in medicine. Debriefing, a process that allows individuals to discuss team performance in a constructive, supportive environment, has been linked to improved performance in various medical and surgical fields, including improvements in specific procedures, teamwork and communication, and error identification. However, the neurosurgical literature on this topic is limited. The authors review the debriefing literature in the field of medicine, with a specific emphasis on the operating room, and they report their own institutional experience with a debriefing module, from invention to pilot implementation, at Vanderbilt University Medical Center. The authors share the challenges and lessons learned from their quality improvement project. The field of neurosurgery would undoubtedly benefit from embracing debriefing, as its potential has been established in other medical specialties and can serve as a valuable role in immediately learning from mistakes. The authors hope that their colleagues can learn from this experience and improve their own. (http://thejns.org/doi/abs/10.3171/2012.8.FOCUS12248)
引用
收藏
页数:8
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