A Kaiser Permanente anesthesiologist has adapted pilots’ pre-flight checklists to the operating room, and now all 30 Kaiser medical centers will use the pre-surgery checks to prevent OR errors and improve staff morale, according to the Orange County Register. James DeFontes, MD, Kaiser’s regional coordinating chief of anesthesia, received training on using the aviation model in the OR from the University of Texas, where researchers found that communication problems were the source of errors and near-misses for pilots and surgical teams. Using Kaiser’s Anaheim Medical Center as a test site, DeFontes developed a routine that requires members of the surgical staff to state their names, the instruments they’ll need, and whether they are new to the team. Staff also double-checks the patient’s name, procedure, and part of the body to be operated on. Since 2002, when the program was implemented, the hospital has had no wrong-site surgeries, but it has reported more near-errors, such as wrong instruments, contamination, and incorrect procedures, due to greater staff collaboration and less fear in speaking up about mistakes. The changes have also led to better staff morale, perceived easier workload, and lower nurse turnover.
