Reducing surgical errors: implementing a three-hinge approach to success

Surgical errors can have serious consequences including patient deaths, and recent reports suggest that surgical errors continue to occur at unacceptable rates. Studies indicate that causative factors for surgical error include human factors, OR interruptions, staffing issues, and error-reporting trends. A "three-hinge" approach can be used to implement a safety program that emphasizes use of a safe surgery checklist and the Centers for Medicare & Medicaid Services reporting requirements for ambulatory surgery centers. The three hinges are the assignment of a change agent, ideally an RN with a doctorate in nursing practice; team cohesiveness; and continuous quality monitoring.