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INTRODUCTION

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  • Why does one team encounter a challenging situation in the operating room and cause harm to a patient, while another team facing the same situation is able to find a different path and safely care for the patient?

  • We spend most of our time in medical training and practice working on what to do, when to do it, and consider the HOW to only be a matter of technical proficiency.

  • Safety is an emergent phenomenon occurring within a system at the interface between the provider and the patient, and includes the knowledge, judgment, technical and nontechnical skills of the provider, and the resources available within a situation.

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BACKGROUND

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The first checklist designed for aviation was created in 1937 for what became the B-17, after a test pilot’s memory lapse contributed to crash, loss of the aircraft, and his own death. The checklist solved one of the pivotal problems recognized by people working in fields of increasing complexity: humans have limited memory, attention span, and ability to carry out multiple tasks simultaneously. At that time a simple tool such as a checklist had high impact with respect to safety because checklists helped the crews prevent the most common mode of failure: mechanical breakdown of the aircraft. The benefit of checklists was immediately apparent, and checklists became standard operating procedure on commercial aircraft from the 1940s onward. Following the invention of the jet engine, however, mechanical failure became extremely rare, and aviation became so predictably safe that a new type of human error became the dominant mode of failure: humans working—or more precisely—not working together. Checklists fail in health care, just as they fail in aviation, when the team assumes safety because of the mere presence of the checklist, as if the checklist were some sort of talisman conferring its benefits on the team and warding off evil. While an appropriately designed checklist will support the creation of such a high-functioning team, it remains the end user who determines the effectiveness of even the best checklist.

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Foundation of Safety

The foundation of safety is maintenance of a coordinated, vigilant team.

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What is the Team’s Function?

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We know the better team is more likely to win the game, and the better team gets out of the dangerous surgical case without harm to the patient more often as well. But what is the work such teams actually do? Task completion for any team, irrespective of the specific endeavor, is dependent upon adequate management of two components: complexity outside the control of the team and mishaps generated by the team. The team’s work toward task completion therefore has been conceptualized as threat and error management (TEM).

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The basic premise of TEM is that no goal-directed activity goes off without a hitch. No matter what you are trying to accomplish, you (or the team) must deal with ...

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