Communication, teamwork, team-coordination – all buzzwords of patient safety and improved healthcare system performance. But does everyone truly know the meaning of these terms? We were presented a case study today in which an experienced and revered surgeon encouraged his surgical team to break protocol by closing a patient when the sponge count was off by one sponge. The surgeon cited, with amiability, the length of time under anesthesia as the urgency for ending the procedure before the missing sponge was accounted for – and rightly so, as longer times under anesthesia are associated with decreased patient outcomes. However, so are surgical materials left in patients. The concerned team deferred to the surgeon’s congenial and persistent request for the sutures to close the patient.
At first glance, this team could be considered to have some of the above qualities: they communicated about the missing sponge, they coordinated a course… Continue reading