Implanted Screwdriver Results in 5.6 Million Dollar Lawsuit: Why Hospitals are Turning to Airline Pilots to Prevent Poor OR Teamwork

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A Hawaiian hospital could have saved a patient’s life, $5.6 million and a shockwave of negative publicity if they had invested in training their surgical teams to use the same assertive communication skills used by flight crews in commercial aviation.

The Institute of Medicine estimates that the total cost of medical errors in U.S. hospitals is an astonishing $17 billion a year. One horrific case of a medical error involved a patient who had the steel shaft of a screwdriver surgically implanted into his spine.

Despite the concerns of the nurses on his surgical team, the surgeon used the screwdriver in place of two titanium rods that turned up missing from the OR when the surgeon needed them. Not wanting to wait, he instead decided to use the screwdriver shaft.

Not long after the surgery, the shaft shattered. More surgeries were needed to correct the complications and ultimately, the patient died. The family was awarded a $5.6 million wrongful death by jury verdict. While the surgeon bears most of the responsibility for the decision, the rest of the surgical team had a part to play in the outcome as well.

To avoid these sorts of decision-making errors and empower nurses on the surgical team to effectively intervene when needed, many hospitals are implementing the aviation-based safety protocols and assertive communication techniques used by commercial flight crews.

One innovative aviation-based safety system, developed by the airline pilots, NASA astronauts, and active physicians of LifeWings Partners LLC, has been implemented in over 40 healthcare facilities nationwide. LifeWings president, Steve Harden, a former Navy pilot and Top Gun instructor says, “The average wrong surgery malpractice award is around $350,000. If just one of these surgical errors is prevented, the return on investment for implementing this safety system is eye-opening. With this system, one of our clients prevented at least six of these claims.”

A major component of the LifeWings’ program focuses on the development of assertive communication behavior among team members. “We’re trying to equip medical teams with the necessary communication behaviors that will help detect and prevent errors before they become harmful to the patient, physician or hospital,” says Harden. “I definitely think the surgical team would never have allowed a screwdriver to be used had the safety system been in place.”

Additionally, LifeWings teaches hospitals how to use standardized checklists. Hospitals learn to create checklists for every procedure to ensure that all surgical equipment is in place. “Had the LifeWings’ system been in place in that hospital, the procedure never would have started until the two missing titanium rods had been found and put in place in the OR,” Harden adds.

Ultimately, LifeWings provides a systematic change to the safety culture in healthcare. The result of that culture change is safer and better quality of care for patients, and thus fewer malpractice claims.

About LifeWings Partners LLC

LifeWings Partners LLC was founded by a former U.S. Navy Top Gun instructor and commercial airline pilot and two physicians who are former NASA astronauts. The firm specializes in applying aviation-based teamwork training and safety tools to help healthcare facilities save patients’ lives and reduce costs. LifeWings has helped over 40 facilities nationwide provide better care to their patients. Measurable results are found in all LifeWings initiatives, including one hospital that experienced a 43% improvement in their observed to expected mortality figures. The firm also conducts Leadership Development workshops for healthcare executive teams.

Contact

Steve Harden, President

LifeWings Partners LLC

800.290.9314

9198 Crestwyn Hills Drive

Memphis, TN 38125

http://www.SaferPatients.com

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