23 July 2014

The Cost of Human Error in the Operating Room

Every year, an estimated 15 million Americans suffer medical harm in hospitals. These errors can be dangerous to patients and also expensive; they cost the health care system $17.1 billion annually.

The most common cause is miscommunication between healthcare workers. Communication errors can be especially dangerous in the operating room; because of this, hospitals have a vested interest in improving communications among OR staff. However, they often turn to admonitions and behavioral sanctions, which are seldom effective.

Recently, some hospitals have looked to other high-risk industries for answers and best practices. Fields as different as aviation, nuclear power, and the military use Crew Resource Management (CRM) to improve communication and ultimately reduce errors and decrease costs.

CRM empowers each OR team member to identify and communicate potential patient harm and contribute equally to the solution. For example, an OR staff member at any level can voice his or her concern by calling a “time out” to immediately pause the surgery in order to discuss the concern or safety issue.

The elements of CRM include: 

  • Pre-procedure briefings 
  • Recognition and verbalization of safety-related red flags
  • Mandatory “time outs”
  • Collaborative creation of standards, procedures, and protocols
  • Empowerment of all team members
  • Immediate post-operative debriefs
  • Culture of continuous improvement

Our next post will examine the roadblocks to CRM and the benefits hospitals have experienced when implementing it. To learn more about reducing human error in the operating room, read our leadership brief.