I am giving no blame, but we learn from the past i
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Posted On: 03/31/2021 1:19:11 PM
Re: MD VIROLOGIST #84895
I am giving no blame, but we learn from the past in science, so to identify what could be improved in the next study. Simple root cause analysis without blaming an individual but to look at system error.
An example the surgeon operates on the wrong leg, I was the chief safety officer, I did not castigate the surgeon, it was a random error, I spent looking for improvement. You may say just mark the leg, well he could still mark the wrong leg in pre op.
The solution was to change the environment in the OR, a surgical pause, empowerment of all voices, and a mandatory checklist.
An example the surgeon operates on the wrong leg, I was the chief safety officer, I did not castigate the surgeon, it was a random error, I spent looking for improvement. You may say just mark the leg, well he could still mark the wrong leg in pre op.
The solution was to change the environment in the OR, a surgical pause, empowerment of all voices, and a mandatory checklist.
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