System Error: One type of Communication Failure in the operating room

Safety Blog Posts: Blog post number 2

System Errors

I will discuss various types of systems error in this blog that result in or may result in lapses of patient safety. There are numerous possible types of system errors. Let’s tackle this one first.

Lack of effective staff Communication Part 1

There are numerous opportunities for errors to occur due to poor communication in any industry; medicine and surgery are no exception.

Staff Empowerment

Lack of staff empowerment by the health care provider (HCP) remains one of the most insidious causes of communication error. The need to have team members with flattened hierarchy enhances team performance. The Dutch psychologist Geert Hofstede studied team performance and is well known for his observations regarding Power Dimension Index (PDI)

Many students of operating room safety compare operating room team performance to the crew that flies an airplane. Malcolm Gladwell in his excellent book “The Outliers” discusses how power dimension index as described by Hofstede in his cultural studies has had an adverse effect on airline safety. Similarly, PDI may have an adverse effect on team performance in the operating room and other areas of patient care.

Here is an excerpt from the current issue of General Surgery News wherein John Paige, MD, associate professor of clinical surgery, LSU Health New Orleans School of Medicine discusses a problem with PDI. The discussion demonstrates how PDI contributed to team dysfunction in an operating room where the team was getting ready to perform a groin hernia operation.

“The Surgeon’s Lounge

Dear Reader,

Welcome to the March issue of The Surgeons’ Lounge General Surgery News. In this issue, John Paige, MD, associate professor of clinical surgery, LSU Health New Orleans School of Medicine, New Orleans, replies to a very timely and interesting operative scenario in which human error is highly possible, but where trainees and other team members are strongly discouraged from voicing concerns, or questioning decisions of the attending (senior) surgeon, even when error is very evident and may negatively affect the patient………..”
Please click on the link that will take you to this article by Dr. Paige in the current issue of General Surgery News

In the next post I will discuss how you for your own safety as the patient can recognize the presence or absence of a flattened hierarchy in a team of health care providers.

Last Update: April 08, 2014