Human Factors in Pediatric Surgery
Despite the paucity of data and experience with human factors research in children, pediatric surgery is increasingly recognizing the impacts of human factors on clinical quality, safety, and outcomes, and the avoidable adverse clinical events are general
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Human Factors in Surgery
Tara N. Cohen • Eric J. Ley Bruce L. Gewertz Editors
Human Factors in Surgery Enhancing Safety and Flow in Patient Care
Editors Tara N. Cohen Cedars-Sinai Medical Center Los Angeles, CA USA
Eric J. Ley Cedars-Sinai Medical Center Los Angeles, CA USA
Bruce L. Gewertz Cedars-Sinai Medical Center Los Angeles, CA USA
ISBN 978-3-030-53126-3 ISBN 978-3-030-53127-0 (eBook) https://doi.org/10.1007/978-3-030-53127-0 © Springer Nature Switzerland AG 2020 This work is subject to copyright. All rights are reserved by the Publisher, whether the whole or part of the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilms or in any other physical way, and transmission or information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed. The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use. The publisher, the authors, and the editors are safe to assume that the advice and information in this book are believed to be true and accurate at the date of publication. Neither the publisher nor the authors or the editors give a warranty, expressed or implied, with respect to the material contained herein or for any errors or omissions that may have been made. The publisher remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. This Springer imprint is published by the registered company Springer Nature Switzerland AG The registered company address is: Gewerbestrasse 11, 6330 Cham, Switzerland
“To our colleagues who selflessly take superb care of patients and make that care safer”
Foreword
Sarah slumped into a chair. “I’m cooked,” she said in a halting voice. A talented surgeon devoted to her patients and to safe surgery, Sarah had performed a “wrong site surgery.” It was her second. Today’s story was easy to piece together. She had four cases scheduled and they proceeded in a manner not unfamiliar to any surgeon. A cholecystectomy had been straightforward until, just as a little bit of bleeding had started, the insufflation failed. Unable to see, Sarah asked that the circulator change the CO2 bottle. The circulator was from another room—the regular circulator was on break. Everybody watched with impatience as the circulator fumbled with the valve. Sarah said, “Yes, in retrospect, I got agitated.” While this case was delayed waiting for help, another force was at work nearby. The two following cases were breast operations. One was a lumpectomy and sentinel node biopsy for breast cancer. So was the case after that. Because one patient had eaten recently, the order of the cases was switched. “The nurse read the timeout in the usual manner,” Sarah to
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