Surgical specimen handover from the operating theatre to laboratoryCan we improve patient safety by learning from aviation and other high-risk organisations?

被引:9
作者
Brennan, Peter A. [1 ,2 ]
Brands, Marieke T. [1 ,2 ]
Caldwell, Lucy [1 ,2 ]
Fonseca, Felipe Paiva [3 ]
Turley, Nic [4 ]
Foley, Susie [4 ]
Rahimi, Siavash [5 ]
机构
[1] Queen Alexandra Hosp, Dept Oral Surg, Portsmouth, Hants, England
[2] Queen Alexandra Hosp, Dept Maxillofacial Surg, Portsmouth, Hants, England
[3] Univ Fed Minas Gerais, Dept Oral Surg & Pathol, Sch Dent, Belo Horizonte, MG, Brazil
[4] NATS, Human Factors, Swanwick, Hants, England
[5] Queen Alexandra Hosp, Dept Histopathol, Portsmouth, Hants, England
关键词
aviation; checklist; handover; pathology specimen; safety; ERROR; CARE; CHECKLIST; QUALITY;
D O I
10.1111/jop.12614
中图分类号
R78 [口腔科学];
学科分类号
1003 ;
摘要
Essential communication between healthcare staff is considered one of the key requirements for both safety and quality care when patients are handed over from one clinical area to other. This is particularly important in environments such as the operating theatre and intensive care where mistakes can be devastating. Health care has learned from other high-risk organisations (HRO) such as aviation where the use of checklists and human factors awareness has virtually eliminated human error and mistakes. To our knowledge, little has been published around ways to improve pathology specimen handover following surgery, with pathology request forms often conveying the bare minimum of information to assist the laboratory staff. Furthermore, the request form might not warn staff about potential hazards. In this article, we provide a brief summary of the factors involved in human error and introduce a novel checklist that can be readily completed at the same time as the routine pathology request form. This additional measure enhances safety, can help to reduce processing and mislabelling errors and provides essential information in a structured way assisting both laboratory staff and pathologists when handling head and neck surgical specimens.
引用
收藏
页码:117 / 120
页数:4
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