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Similar to others, the participants in these calls concluded that creation of lengthy policies and checklists
that do not pertain to a particular institution or team
may be more likely to create bigger problems rather
than solve them. Additionally, they felt that single
episode/one-size-fits-all training is unlikely to have lasting effects as it may not “touch the heart and soul of the
team.” They acknowledged that success requires a multi-tiered approach to overcome this hurdle. 5, 6, 9 They also
agreed that institutional leadership must be aware of the
upstream and downstream interferences that occur prior
to or after the OR universal protocol time-out checklist
verifications. 25 Finally, our surgeons expressed concerns
that institutional focus specifically on the surgical team
involved in an adverse event, while ignoring systemic
issues, will ultimately lead to loss of motivation and subsequent burnout.
The health care industry has numerous hurdles to
scale to reach the goal of improved patient safety and
high reliability, but if we are unified, it is a goal within
our grasp. ♦
The content of this article represents the opinions of the
authors and the researchers cited herein and does not represent the opinion of the U. S. government, the U.S. Department
of Veterans Affairs, or the Veterans Health Administration.
The public and many hospital administrators are focused
on zero tolerance of error or adverse events. Too often
hospital committees focus on individual untoward events
without regard to the context surrounding the error.