Using a checklist might have prevented Sheila Hynes death in March 2017, after her new heart valve was put in upside down. The two Simons asked us, “What goes wrong in your theatre?” Reasons for errors include the pressure of time, distractions, last minute changes, inadequate preparation, assumptions, inadequate help, incomplete information, and the “system”—people, resources, and how they are dispersed.
Human factors, leadership, and communication, all included in non-technical skills, are the top three contributors to Sentinel Events, unexpected events in a healthcare setting that kill or harm patients and that are unrelated to the patients’ illness.
As I learned, NOTSS is not about bad guys, remediation, catastrophic failure, blame/attribution, or extraordinary events. And there is no single vaccination for immunity.
NOTSS is about normal people, places, organizations, and systems. It’s about recognizing complexity and optimizing performance.
Situational awareness
High on the list of necessary skills for effective surgeons is situational awareness, or being aware of what’s around you even as you focus on the task of surgery. Check out this video to test your own situational awareness.
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