M. M. Dierks

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BACKGROUND To better understand the operating room as a system and to identify system features that influence patient safety, we performed an analysis of operating room patient care using a prospective observational technique. METHODS A multidisciplinary team comprised of human factors experts and surgeons conducted prospective observations of 10 complex(More)
3 With increasing attention to patient safety, hospitals and other clinical facilities are developing practice guidelines and protocols with the specific intent of reducing harm to patients. However, the introduction of these protocols can have unanticipated negative consequences and if followed rigidly can become 'disabling'. We use the manual count(More)
Risk is an inherent part of healthcare, particularly in large referral centers, where some of the most complex cases are managed. While risk cannot be eliminated from the clinical activities, it is believed that some practices involving unnecessary risk can be mitigated without impacting overall performance. Our ability to identify these vulnerable(More)
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