Written by Andy Smith, MTM publisher

All are aware that the operating room can be a high stress environment in which highly complex and intricate procedures are carried out by very talented and caring healthcare professionals.

Despite good intent and high levels of skill the likelihood of a series of small errors is high compared to other high stakes enterprises, and the cost of the ultimate error can be fatal to the patient and extremely damaging to those responsible.

Various studies in different countries offer error rates affecting as many as 10% of patients, another says 7.5% of patients suffer an adverse experience and 37.5% of those errors are avoidable. Those percentages are very high and all would agree they are unacceptable.

Had the airline industry stuck to its 1950’s thinking, we could by now be seeing a weekly air accident. Had Alcoa stuck to the historic ‘smelting is a dangerous business, we have to expect problems,’ it would not have achieved record profits, and saved their employees from death or injury.

The OR Black Box continues to demonstrate the potential to learn from experience, both individually and as teams to improve performance and safety.

A colleague recently provided an excellent quote from Winston Churchill; "To improve is to change; to be perfect is to change often.”

Can healthcare change of its own volition or will government have to change it? I for one sincerely hope it can but the clock is ticking.