A Delicate Balance - Adaptive Design and Team Learning in the Operating Theatre

Abstract

Since the publication of the Institute of Medicine (IOM) study “To Err is human”, followed by “Crossing the Quality Chasm” two years later, patient safety has become an important concern for all involved: patients, professionals and health care organisations (Bleich, 2005; Kohn, 2000). Over the last 10 years, significant improvements have been made and many innovative initiatives resulted in enhanced patient safety. At both national and international level checklists and performance indicators were developed, handovers restructured and reporting systems installed (Haynes et al., 2009; Lingard et al., 2005; Pronovost, Thompson, et al., 2006; Riesenberg et al., 2009). Recently, also patients are involved in patient safety initiatives (Conrardy, Brenek, & Myers, 2010; Davis, Koutantji, & Vincent, 2008). Although we have come a long way, there is room for improvement as research shows that medical errors and, more alarming, preventable medical errors still occur (Bleich, 2005; Zegers et al., 2009).