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To Err is Human, to Get it Right Takes a Village

Cora Nucci, for HealthLeaders Media, October 20, 2010

A study and a related editorial in Wednesday's Journal of the American Medical Association remind us of a fundamental, yet elusive truth of the operating room: two (or more) heads are better than one, especially if they're working together, toward a shared goal.

In the OR it's not the superstar surgeon working as a solo act who has the best outcomes; it's the surgeon who has gathered a staff of strong individuals and led them to act as a finely calibrated team.

But, as an unrelated study puts it: "Sadly, teamwork among the various professionals within the OR is often flawed: Communication is poor, roles are at best ambiguous, and the organizational structure of the team is often unwanted. Furthermore, team members tend to underestimate their individual weaknesses and overestimate their own teamwork abilities and contributions."

These behaviors can lead to medical errors. Among the most common, hemorrhage complicating a procedure, accidental puncture or laceration during a procedure, hematoma complicating a procedure, or mechanical complication of a cardiac device, implant, or graft. But don't expect a shout if something goes wrong in the OR.

The post-9/11 mantra, "if you see something, say something," so familiar to riders of public transportation, is as welcome in the OR as a muddy boot. Says the JAMA editorial: " in many health care sentinel events, a member of the health care team knew something was wrong but either did not speak up or spoke up and was ignored." It's not just in the OR, by the way, that colleagues don't report colleagues. The practice is widespread.

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