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Published 5/1/2011
S. Jay Jayasankar, MD

What does it take to make our practices safe?

Invisible elements include personal awareness, leadership, and decision-making skills

As orthopaedic surgeons, we are constantly honing our professional knowledge and skills; we, our practice staff, and our hospital teams are increasingly patient safety conscious. How, then, does patient safety elude us?

These foundational ‘safety blocks’ need to be held together by practice skills that make up the ‘invisible mortar.’ A seminal element of this mortar is our mindfulness. The dictionary definitions of mindfulness include being aware, bearing in mind, and actively attentive. Mindfulness requires our nonjudgmental presence in the now and attention to our own physical and mental processes during routine tasks.

Some of the attitudes associated with mindfulness include having a beginner’s mind, which sees everything as new; letting go of other competing thoughts or concerns; and accepting the situation as it truly is instead of as we might wish it to be. Mindfulness can be improved by training, and enhanced mindfulness improves physician well-being and can reduce medical errors. Overwork, tiredness, distractions, and “I’ve-been-there” attitudes detract from mindfulness.

Another invisible element is our leadership, to lead others while remaining part of the team, to rid ourselves of hierarchical arrogance and encourage sharing responsibility for achieving goals. This distributive leadership gives team members ownership in specific and overlapping areas, encourages them to be proactive, and ensures their commitment to the overall success of the team. Team members speak up to enhance patient safety and are acknowledged for their alertness and contribution.

The founder and former CEO of the VISA credit card association, Dee Hock, uses the term chaordic to describe a form of consensus decision-making (in the case of surgery, it would be for specific steps or processes) that is most suited to the human spirit. The attitudinal change from the ‘captain-of-the-ship’ hierarchical leadership model does require effort but does not alter the central and leading role of the physician.

Decision-making skills and attitudes
As surgeons, we are constantly evaluating situations, drawing conclusions, and deciding on action in perisurgical and nonsurgical situations. We gather facts, analyze relevancy, include or exclude, integrate, and, when necessary, use instant decision-making strategies
(Fig. 1).

When working with inadequate information or time, we use strategies and heuristics that call upon our best knowledge supplemented with past experience. These strategies require considerable and demanding mental processes that continually take into account whatever ongoing additional information can be developed. In these situations, the demand for mindfulness, leadership, and a highly functional team is heightened.

A reflexive or routine response or action—one that does not consider the specific situation and information—must be avoided. We may know what to do in a given situation, but fail to take appropriate steps because we did not recognize the situation for what it is. This failure to recognize a situation or risk in patient care can lead to diagnostic errors and has received inadequate attention in patient safety. Checklists are effective, but are, in the end, only as good as how we implement them and lead our teams in following them.

If we are not looking for specific information, we are likely to pass by it. Our information selection bias, although it can be helpful when mindfully applied, may also result in selection error leading to diagnostic/decision error.

Our role as patient advocates is to identify, acknowledge, and correct the failure. Otherwise, we fail in our fiduciary responsibility and our profession’s implied compact with the public for the professional privilege granted us. The liability system’s focus on establishing fault should not distract us.

Our continual quest for knowledge and skills should include these invisible mortar skills and an awareness of how we think and make decisions. Both self- and external evaluations (including the Orthopaedic In-Training Exam and Maintenance of Certification™) should include and encourage development of these skills, and our profession should collectively advance knowledge and training in them.

You be the judge
Many AAOS Now readers responded to the December 2010 Orthopaedic Risk Manager article, “You be the judge.” The article summarized the outcome from an actual trial following a postoperative patient death from deep venous thrombosis (DVT)/pulmonary embolism. Although opinions differed on the negligence of the defendant, respondents agreed that prophylactic anticoagulation should have been used and would likely have prevented the patient’s death. The court records indicate that the physician in the case also concurred, but had neither obtained nor read the nurse’s notes of the patient’s past history of serious DVT.

Many of the responses also highlighted the disconnect between the nurses’ knowledge and notes about the patient and those of the physician.

S. Jay Jayasankar, MD, is a member of the AAOS Medical Liability Committee. He can be reached at jaymd@massmed.org


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