Think using checklists is a low hanging fruit type of change that can be instituted in almost all hospitals in our country, given the sheer number of nursing students who are having their ojt’s its actually quite sad that such simple techniques is not as widespread as it can be.
In my field of surgery, there are some unforgivable errors. Although some of us may disagree on the exact identity of some of them, most surgeons would agree on a handful of them. Certainly one of them would be to amputate the wrong limb or remove the wrong organ. This happens far more often than any of us would like to admit. Over the last couple of decades, checklists meant to prevent such occurrences have risen to the fore and become standard practice at most hopsitals. We surgeons ridicule them (myself included, at least until recently), but they work, as an increasing amount of scientific and clinical literature is showing. Another unforgivable error is to leave a sponge or surgical instrument behind during an uncomplicated elective case. I qualify that because it’s understandable that occasionally a sponge will be left behind in a trauma case or when an elective case goes bad. In both cases, things get crazy, and everyone is frantically trying to save the patient. But in the elective case, leaving a sponge or surgical instrument behind should in essence never happen. The tedious ritual of counting the sponges, needles, and instruments before and after the case is highly effective in preventing it–when surgeons listen to the nurse telling them that the counts aren’t correct. The third unforgivable error is to operate on the wrong patient, which has occasionally happened in the past. Again, checklists make such a spectacular mistake much less likely. At my own hospital, for instance, the nurses are required to ask each patient who he or she is, what operation she is having, who the surgeon is, and, if it’s appropriate for the operation, which side is being operated on. The surgeon is required to mark the body part and the side with his or her initials. Sure it sounds silly and pointless, but it’s clear that such systems reduce wrong site surgery markedly.
via Unforgivable medical errors : Respectful Insolence.