Transcript of NoCVA Safe Surgery Collaborative Teamwork Training Speaking Up April 4, 2013 NoCVA Hospital...
- Slide 1
- Slide 2
- NoCVA Safe Surgery Collaborative Teamwork Training Speaking Up
April 4, 2013 NoCVA Hospital Engagement Network
- Slide 3
- The Problem
- Slide 4
- A Story Patient has known allergy to chlorhexidine. Patient was
asleep and positioned ready for surgery. The team was waiting for
the surgeon. No chlorhexidine had been used. The surgeon enters in
a rush and he grabs chlorhexidine and begins to prep the patient
himself. Everybody in the room knew that the patient had an
allergy, except for the surgeon. Nobody says anything. Patient goes
into anaphylaxis shock.
- Slide 5
- Why Dont We Speak Up Im afraid Im embarrassed Im stupid They
will yell at me I might be wrong The surgeon is mean They wont
listen anyway Its not that important
- Slide 6
- The Joint Commission has found that many times when sentinel
events occur in the OR a member of the surgical team knew that the
event was about to happen and they didnt say anything.
- Slide 7
- Events That Have Happened Because Nobody Spoke Up Wrong Site
Wrong Procedure Wrong Equipment Wrong/Missing Implant Wrong
Medication/Allergy
- Slide 8
- The Solution Use special words that indicate that there is a
problem. Both the sender and the receiver need to understand these
words.
- Slide 9
- Slide 10
- How To Use CUS First, state your CONCERN. Then state why you
are UNCOMFORTABLE If the problem is still not solved, state that
there is a SAFETY ISSUE.
- Slide 11
- Ideally, everyone will understand and know how to use CUS, but
CUS can also work if only the sender uses it.
- Slide 12
- What Does CUS Sound Like?
- Slide 13
- Now Lets Practice... Im Concerned Im Uncomfortable This is a
Safety Issue