SaferPatients

Here’s the account of a surgeon falling asleep in the OR during two successive surgeries. The story appeared in the Boston Globe.

“When Dr. Loren J. Borud began his first case at about 8 a.m., an operating room nurse noticed he looked tired and wobbly. She was so concerned, according to one account of the Friday last June, that she suggested Borud postpone his next patient.

Borud said he had been up all night working on a book, but he kept operating, starting a second case, during which he briefly fell asleep, according to a report from state investigators. The nurse again called him aside and suggested “maybe he should take a break,” according to her interviews with investigators, but he continued the surgery.

The operating room nurse called the plastic surgery department twice to report Borud’s behavior that morning and early afternoon, the report said, and the office nurse told her to “keep an eye on him.” But no senior surgeon or administrator ordered Borud to stop operating - even though there was widespread awareness of his history of drug and alcohol abuse, according to investigators. Read more »

Since I last made a blog entry you no doubt saw the all of the coverage of Capt. “Sully” and the miraculous ditching of the crippled A-320 in the Hudson river in New York City.

Lately, I have had a lot of questions from medical audiences about the event during my public speaking. Everyone wants to know the inside story. Read more »

With the advent of the World Health Organization (WHO) surgical safety checklist, a lot of facilities in the U.S. are trying to implement a checklist as a vehicle to accomplish the Universal Protocol (Time Out). Not everyone who tries it succeeds, and they seem very surprised when they don’t.  Why? Read more »

I get a lot of calls from healthcare folks wanting to change the culture in their organization. Our discussions have a lot of back and forth - most of it centered on helping them overcome the obstacles they see to getting started on the culture changing process. This week alone, I’ve had five lengthy discussions with potential clients and several email exchanges. Read more »

I just got off the phone with the Associate Dean of Clinical Effectiveness at a large hospital in the south. His institution, like everyone else it seems, has spent a lot of time and attention on the HCAHPS results that now show up on the HHS Hospital Compare web site. Read more »

Measurement. How to measure, what to measure, when to measure, who should measure, where to measure. Despite the “culture of measurement” that exists in most hospitals today, I continue to get these type of questions after almost every presentation I give about implementing aviation-based teamwork and safety tools in healthcare. Read more »

Conversations with low performers are always hard to have. Nobody likes them, everybody dreads them. Consequently, they don’t get done near as often as they should. Unfortunately, no one wins, not even the low performer, when the needed conversation is avoided. Read more »

In a recent survey of nurses, physicians, and administrators 96% of respondents say they had witnessed or experienced disruptive behavior from a physician.

In my first post, I wrote about becoming a “Topgun” or being the best of the best. Read more »

Samuel Johnson wrote in 1759, “Nothing will ever be attempted, if all possible objections must be first overcome.” I work with a lot of hospitals to help them adopt some of the best practices (things like teamwork training and checklists) from aviation to improve their patient safety and quality of care. Read more »

I am traveling today on an airline. It will come as no surprise to you that I am writing this while sitting in the gate area - waiting to board.With a little time on my hands, my thoughts drifted to the hundreds of times this exact scene has repeated itself in my life. Read more »