Errors, verification and prevention

Craig Silverman RegretTheError.com CraigSilverman.ca @Craigsilverman

Why Errors Occur

“It is often the best people who make the worst mistakes—error 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 Verification

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 first. What you don’t know is just as, or more, important as what you do. Hedging often gets stripped, so work to confirm 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-giffords/ 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 Verification: http://www.cjr.org/

Prevention

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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