Errors, verication and prevention

Craig Silverman RegretTheError.com CraigSilverman.ca @Craigsilverman

Why Errors Occur

It is often the best people who make the worst mistakeserror is not the monopoly of an unfortunate few...far from being random, mishaps tend to fall into recurrent patterns. The same set of circumstances can provoke similar errors, regardless of the people involved. -- James Reason

Pound for pound, the most mistake-packed article I have ever checked was written by a Pulitzer Prize winner.
-- Ariel Hart, Columbia Journalism Review

Errors Occur

Errors Occur

Errors Occur

Errors Occur

Errors Occur

Frequency of Errors

Error Rate
70+ years of research 40%-60% of news stories contain an
error

Subjective vs. Objective Meyer method = 25%

Common Errors
1. Misquotes 2.Incorrect headline 3. Numerical error 4.Misspelling 5.Incorrect job title 6.Incorrect name 7.Incorrect location 8.Incorrect time 9.Incorrect date 10.Incorrect address 11.Incorrect age

Social Media Verication

Law of Incorrect Tweets

The initial, mistaken information will be retweeted more than any subsequent correction

Lessons

Andy is not just about SM. Lots of old school work comes rst. What you dont know is just as, or more, important as what you do. Hedging often gets stripped, so work to conrm before you tweet Questions encourage interaction, convey uncertainty. He RTs and adds context and info.

Verifying Real-Time/SM Info

Track back RTs, etc. to source Look for clusters Location enabled? Evaluate the network Evaluate the history Links, photos? Take it old school Disclose, hedge, repeat Be brave only in correction

Links
Giffords Error: http://
www.regrettheerror.com/2011/01/08/nprreuters-cnn-and-other-major-news-orgsincorrectly-declare-death-of-rep-giords/ behind_the_news/eruption_interrupted.php? page=all the_news_frontier/ best_practices_for_social_medi.php?page=all

Correcting Tweets: http://www.cjr.org/ SM Verication: http://www.cjr.org/

Prevention

!"#$%&'()*+,&-./0-+1)*2**2343456**26.52**708#*2

SURGICAL SAFETY CHECKLIST (FIRST EDITION)

Before induction of anaesthesia
SIGN IN
PATIENT HAS CONFIRMED IDENTITY SITE PROCEDURE CONSENT SITE MARKED/NOT APPLICABLE ANAESTHESIA SAFETY CHECK COMPLETED PULSE OXIMETER ON PATIENT AND FUNCTIONING DOES PATIENT HAVE A: KNOWN ALLERGY? NO YES DIFFICULT AIRWAY/ASPIRATION RISK? NO YES, AND EQUIPMENT/ASSISTANCE AVAILABLE RISK OF >500ML BLOOD LOSS (7ML/KG IN CHILDREN)? NO YES, AND ADEQUATE INTRAVENOUS ACCESS AND FLUIDS PLANNED

Before skin incision

TIME OUT
CONFIRM ALL TEAM MEMBERS HAVE INTRODUCED THEMSELVES BY NAME AND ROLE SURGEON, ANAESTHESIA PROFESSIONAL AND NURSE VERBALLY CONFIRM PATIENT SITE PROCEDURE ANTICIPATED CRITICAL EVENTS SURGEON REVIEWS: WHAT ARE THE CRITICAL OR UNEXPECTED STEPS, OPERATIVE DURATION, ANTICIPATED BLOOD LOSS? ANAESTHESIA TEAM REVIEWS: ARE THERE ANY PATIENT-SPECIFIC CONCERNS? NURSING TEAM REVIEWS: HAS STERILITY (INCLUDING INDICATOR RESULTS) BEEN CONFIRMED? ARE THERE EQUIPMENT ISSUES OR ANY CONCERNS? HAS ANTIBIOTIC PROPHYLAXIS BEEN GIVEN WITHIN THE LAST 60 MINUTES? YES NOT APPLICABLE IS ESSENTIAL IMAGING DISPLAYED? YES NOT APPLICABLE

Before patient leaves operating room

SIGN OUT
NURSE VERBALLY CONFIRMS WITH THE TEAM: THE NAME OF THE PROCEDURE RECORDED THAT INSTRUMENT, SPONGE AND NEEDLE COUNTS ARE CORRECT (OR NOT APPLICABLE) HOW THE SPECIMEN IS LABELLED (INCLUDING PATIENT NAME) WHETHER THERE ARE ANY EQUIPMENT PROBLEMS TO BE ADDRESSED SURGEON, ANAESTHESIA PROFESSIONAL AND NURSE REVIEW THE KEY CONCERNS FOR RECOVERY AND MANAGEMENT OF THIS PATIENT

THIS CHECKLIST IS NOT INTENDED TO BE COMPREHENSIVE. ADDITIONS AND MODIFICATIONS TO FIT LOCAL PRACTICE ARE ENCOURAGED.

WHO surgical safety checklist helped reduce inpatient deaths following operations by 40 percent -- New England Journal of
Medicine

Why?
Remove reliance on memory Prevent distraction Central collection point Introduce repeatable, measurable process Create discipline (force) necessary for high
performance

Tips
Increase font size while reviewing work Ask to spell name/title Keep research in separate font, color from
your writing color

Keep items TK or to check in yet another 5-minute rule