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Errors, verification and prevention Craig Silverman RegretTheError.com CraigSilverman.ca @Craigsilverman

Errors, verification and prevention

Craig Silverman RegretTheError.com CraigSilverman.ca @Craigsilverman

Why Errors Occur

“It is often the best people who make the

worst mistakes error is not the monopoly

of an unfortunate few

random, mishaps tend to fall into recurrent patterns. The same set of circumstances can provoke similar errors, regardless of the people involved.” -- James Reason

far

from being

“Pound for pound, the most mistake- packed article I have ever checked was written by a Pulitzer Prize winner.”

-- Ariel Hart, Columbia Journalism Review

Errors Occur

Errors Occur

Errors Occur

Errors Occur

Errors Occur

Errors Occur

Errors Occur

Errors Occur
Errors Occur
Errors Occur
Errors Occur
Errors Occur

Errors Occur

Errors Occur

Frequency of Errors

Error Rate

70+ years of research

40%-60% of news stories contain an error

Subjective vs. Objective

Meyer method = 25%

Common Errors

1.Misquotes

2.Incorrect headline 3.Numerical error

4.Misspelling

5.Incorrect job title 6.Incorrect name 7.Incorrect location 8.Incorrect time 9.Incorrect date 10.Incorrect address 11.Incorrect age

Social Media Verification

Law of Incorrect Tweets

The initial, mistaken information will be retweeted more than any subsequent correction

Lessons

Andy is not just about SM. Lots of old school work comes first.

What you don’t know is just as, or more, important as what you do.

Hedging often gets stripped, so work to confirm before you tweet

Questions encourage interaction, convey uncertainty.

He RTs and adds context and info.

Verifying Real -Time/SM Info

Track back RTs, etc. to source

Look for clusters

Location enabled?

Evaluate the network

Evaluate the history

Links, photos?

Take it old school

Disclose, hedge, repeat

Be brave only in correction

Prevention

* **

*

**

**

*

S URGICAL S AFETY C HECKLIST (F IRST E DITION )

SURGICAL SAFETY CHECKLIST (FIRST EDITION)

Before induction of anaesthesia

Before induction of anaesthesia SIGN IN   PATIENT HAS CONFIRMED • IDENTITY • SITE •

SIGN IN

 
PATIENT HAS CONFIRMED

PATIENT HAS CONFIRMED

IDENTITY

SITE

PROCEDURE

CONSENT

SITE MARKED/NOT APPLICABLE

SITE MARKED/NOT APPLICABLE

ANAESTHESIA SAFETY CHECK COMPLETED

ANAESTHESIA SAFETY CHECK COMPLETED

PULSE OXIMETER ON PATIENT AND FUNCTIONING

PULSE OXIMETER ON PATIENT AND FUNCTIONING

 

DOES PATIENT HAVE A:

KNOWN ALLERGY?

NO

NO

YES

YES

 

DIFFICULT AIRWAY/ASPIRATION RISK?

NO

NO

YES, AND EQUIPMENT/ASSISTANCE AVAILABLE

YES, AND EQUIPMENT/ASSISTANCE AVAILABLE

RISK OF >500ML BLOOD LOSS (7ML/KG IN CHILDREN)?

NO

NO

YES, AND ADEQUATE INTRAVENOUS ACCESS AND FLUIDS PLANNED

YES, AND ADEQUATE INTRAVENOUS ACCESS AND FLUIDS PLANNED

Before skin incision

INTRAVENOUS ACCESS AND FLUIDS PLANNED Before skin incision TIME OUT CONFIRM ALL TEAM MEMBERS HAVE INTRODUCED

TIME OUT

CONFIRM ALL TEAM MEMBERS HAVE INTRODUCED THEMSELVES BY NAME AND ROLE

CONFIRM ALL TEAM MEMBERS HAVE INTRODUCED THEMSELVES BY NAME AND ROLE

SURGEON, ANAESTHESIA PROFESSIONAL AND NURSE VERBALLY CONFIRM

SURGEON, ANAESTHESIA PROFESSIONAL AND NURSE VERBALLY CONFIRM

PATIENT

SITE

PROCEDURE

 

ANTICIPATED CRITICAL EVENTS

SURGEON REVIEWS: WHAT ARE THE CRITICAL OR UNEXPECTED STEPS, OPERATIVE DURATION, ANTICIPATED BLOOD LOSS?

SURGEON REVIEWS: WHAT ARE THE CRITICAL OR UNEXPECTED STEPS, OPERATIVE DURATION, ANTICIPATED BLOOD LOSS?

ANAESTHESIA TEAM REVIEWS : ARE THERE ANY PATIENT-SPECIFIC CONCERNS?

ANAESTHESIA TEAM REVIEWS: ARE THERE ANY PATIENT-SPECIFIC CONCERNS?

NURSING TEAM REVIEWS: HAS STERILITY (INCLUDING INDICATOR RESULTS) BEEN CONFIRMED? ARE THERE EQUIPMENT ISSUES OR

NURSING TEAM REVIEWS: HAS STERILITY (INCLUDING INDICATOR RESULTS) BEEN CONFIRMED? ARE THERE EQUIPMENT ISSUES OR ANY CONCERNS?

 

HAS ANTIBIOTIC PROPHYLAXIS BEEN GIVEN WITHIN THE LAST 60 MINUTES?

YES

YES

NOT APPLICABLE

NOT APPLICABLE

IS ESSENTIAL IMAGING DISPLAYED?

YES

YES

NOT APPLICABLE

NOT APPLICABLE

Before patient leaves operating room

SIGN OUT

 

NURSE VERBALLY CONFIRMS WITH THE TEAM:

THE NAME OF THE PROCEDURE RECORDED

THE NAME OF THE PROCEDURE RECORDED

THAT INSTRUMENT, SPONGE AND NEEDLE COUNTS ARE CORRECT (OR NOT APPLICABLE)

THAT INSTRUMENT, SPONGE AND NEEDLE COUNTS ARE CORRECT (OR NOT APPLICABLE)

HOW THE SPECIMEN IS LABELLED (INCLUDING PATIENT NAME)

HOW THE SPECIMEN IS LABELLED (INCLUDING PATIENT NAME)

WHETHER THERE ARE ANY EQUIPMENT PROBLEMS TO BE ADDRESSED

WHETHER THERE ARE ANY EQUIPMENT PROBLEMS TO BE ADDRESSED

SURGEON, ANAESTHESIA PROFESSIONAL AND NURSE REVIEW THE KEY CONCERNS FOR RECOVERY AND MANAGEMENT OF THIS

SURGEON, ANAESTHESIA PROFESSIONAL AND NURSE REVIEW THE KEY CONCERNS FOR RECOVERY AND MANAGEMENT OF THIS PATIENT

THIS CHECKLIST IS NOT INTENDED TO BE COMPREHENSIVE. ADDITIONS AND MODIFICATIONS TO FIT LOCAL PRACTICE ARE ENCOURAGED.

WHO surgical safety checklist helped reduce inpatient deaths following operations by 40

percent -- New England Journal of Medicine

Why?

Remove reliance on memory

Prevent distraction

Central collection point

Introduce repeatable, measurable process

Create discipline ( “force” ) necessary for high performance

Tips

Increase font size while reviewing work

Ask to spell name/title

Keep research in separate font, color from your writing

Keep items TK or to check in yet another color

5 - minute rule