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Checklist Program and Development

In complex team environments like the operating room, humans can become task saturated and are more susceptible to making preventable errors; more than half of surgical adverse events are preventable.[1] Checklists are a simple, proven, and effective tool that can decrease morbidity and reduce malpractice actions by reducing the incidence of preventable errors, without limiting the physician’s agency or discretion. Checklists also have the potential to lead to better patient outcomes by allowing the user to allocate more mental focus on complex elements of the procedure instead of trying to remember what, or if, certain critical routine steps have been accomplished.


[1] Gawande AA, Thomas EJ, Zinner MJ, Brennan TA. The incidence and nature of surgical adverse events in Colorado and Utah in 1992. Surgery. 1999;126:66–75. 


Crew Resource Management (CRM) Training

Crew Resource Management is the practice of prioritizing and utilizing a team's resources in the most effective way possible. It incorporates methods for effective communication, situational awareness, leadership, and prioritization. It is largely credited as one of the primary catalysts for the dramatic improvement in aviation safety following an era of high profile preventable accidents. These human factor principles can be applied to any complex team enviornment, including and espicially in healthcare.


Threat and Error Management (TEM) Training

A single error is almost never the proximate cause of an accident. It is almost always a series of errors that collectively result in an adverse outcome. Threat and error management is a methodical approach to identifying and managing threats and errors before they result in an adverse outcome. Like CRM, TEM can be applied in any complex team setting.


"Sterile" Flight Deck Rule/Sealed OR Rule

The sterile flight deck rule is a Federal Regulation that applies to pilots of commercial aircraft which prohibits any nonessential conversation or activity during any critical phase of flight. Explore how implementing objective standards concerning operating room entry, activity, and conversation can help reduce preventable errors. 



Standardization improves safety by eliminating any uncertainty about how certain procedures and workflows are to be performed. Errors decrease when clear expectations are set and providers don't have to anticipate how other members on the team prefer to accomplish a routine task. Providers become more interchangeable and deviation from proper practice becomes easier to identify. Not every task and procedure should be standardized, however. Some things are left better to provider discretion and technique. Identify areas where your facility can benefit from standardizing workflow. 


Professional Standards Committee Development

A crucial element of any safe organization is the means and willingness for people to report unsafe or improper performance. Employees are generally reluctant or unwilling to report other employees directly to management when doing so may result in unfavorable outcomes for their fellow employee. Explore ways to maintain accountability and acceptable standards of professionalism without disincentivizing report


Safety Risk Assessment Programs (SRA/SRM/SMS)

Implement a formal program designed to identify safety hazards, analyze and assess risk, and develop controls to reduce risk to an acceptable level.


Observational Safety Audit Development

Develop a program designed to identify and mange systemic risk through internal audits. 


No-Fault Safety Reporting

An internal reporting program that incentivizes providers to self disclose errors improves safety by helping facilities proactively identify internal risks and problematic trends before they result in an adverse event. 

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