Communication breakdowns in the perioperative environment are a factor in 70% of events that adversely affect patients. Sometimes those breakdowns occur because OR staff are reluctant to voice their concerns in an environment that is hierarchical and intimidating. However, when an organization adopts patient safety first (PSF) initiatives, adverse outcomes can dramatically diminish—or even disappear, as was the case at The Medical Center of Aurora (TMCA) in Aurora, Colorado, which eliminated never events.
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