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Errors, verification andprevention

Craig Silverman

RegretTheError.comCraigSilverman.ca@Craigsilverman

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Why Errors Occur

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It is often the best people who make theworst mistakeserror is not the monopolyof an unfortunate few...far from being

random, mishaps tend to fall intorecurrent patterns. The same set ofcircumstances can provoke similar errors,regardless of the people involved.

-- James Reason

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Pound for pound, themost mistake-packed

article I have everchecked was written by aPulitzer Prize winner.-- Ariel Hart, Columbia Journalism

Review

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Errors Occur

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Errors Occur

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Errors Occur

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Errors Occur

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Errors Occur

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Frequency of Errors

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Error Rate

70+ years of research

40%-60% of news stories contain an

error

Subjective vs. Objective

Meyer method = 25%

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Common Errors1.Misquotes

2.Incorrect headline

3.Numerical error

4.Misspelling

5.Incorrect job title

6.Incorrect name

7.Incorrect location

8.Incorrect time

9.Incorrect date

10.Incorrect address

11.Incorrect age

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Social MediaVerification

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Law of Incorrect

Tweets

The initial, mistaken information will beretweeted more than any subsequentcorrection

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Lessons Andy is not just about SM. Lots of old school

work comes first.

What you dont know is just as, or more,important as what you do.

Hedging often gets stripped, so work to confirmbefore you tweet

Questions encourage interaction, conveyuncertainty.

He RTs and adds context and info.

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Verifying Real-Time/SM Info

Track back RTs, etc. to source Look for clusters Location enabled? Evaluate the network Evaluate the history

Links, photos?

Take it old school Disclose, hedge, repeat

Be brave only in correction

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Links Gifords Error: http://

www.regrettheerror.com/2011/01/08/npr-reuters-cnn-and-other-major-news-orgs-

incorrectly-declare-death-of-rep-giffords/ Correcting Tweets: http://www.cjr.org/

behind_the_news/eruption_interrupted.php?page=all

SM Verification: http://www.cjr.org/the_news_frontier/best_practices_for_social_medi.php?page=all

http://www.cjr.org/the_news_frontier/best_practices_for_social_medi.php?page=allhttp://www.cjr.org/the_news_frontier/best_practices_for_social_medi.php?page=allhttp://www.cjr.org/the_news_frontier/best_practices_for_social_medi.php?page=allhttp://www.cjr.org/the_news_frontier/best_practices_for_social_medi.php?page=allhttp://www.cjr.org/the_news_frontier/best_practices_for_social_medi.php?page=allhttp://www.cjr.org/the_news_frontier/best_practices_for_social_medi.php?page=allhttp://www.cjr.org/the_news_frontier/best_practices_for_social_medi.php?page=allhttp://www.cjr.org/the_news_frontier/best_practices_for_social_medi.php?page=allhttp://www.cjr.org/the_news_frontier/best_practices_for_social_medi.php?page=allhttp://www.cjr.org/the_news_frontier/best_practices_for_social_medi.php?page=allhttp://www.cjr.org/behind_the_news/eruption_interrupted.php?page=allhttp://www.cjr.org/behind_the_news/eruption_interrupted.php?page=allhttp://www.cjr.org/behind_the_news/eruption_interrupted.php?page=allhttp://www.cjr.org/behind_the_news/eruption_interrupted.php?page=allhttp://www.cjr.org/behind_the_news/eruption_interrupted.php?page=allhttp://www.cjr.org/behind_the_news/eruption_interrupted.php?page=allhttp://www.regrettheerror.com/2011/01/08/npr-reuters-cnn-and-other-major-news-orgs-incorrectly-declare-death-of-rep-giffords/http://www.regrettheerror.com/2011/01/08/npr-reuters-cnn-and-other-major-news-orgs-incorrectly-declare-death-of-rep-giffords/http://www.regrettheerror.com/2011/01/08/npr-reuters-cnn-and-other-major-news-orgs-incorrectly-declare-death-of-rep-giffords/http://www.regrettheerror.com/2011/01/08/npr-reuters-cnn-and-other-major-news-orgs-incorrectly-declare-death-of-rep-giffords/http://www.regrettheerror.com/2011/01/08/npr-reuters-cnn-and-other-major-news-orgs-incorrectly-declare-death-of-rep-giffords/http://www.cjr.org/the_news_frontier/best_practices_for_social_medi.php?page=allhttp://www.cjr.org/the_news_frontier/best_practices_for_social_medi.php?page=allhttp://www.cjr.org/the_news_frontier/best_practices_for_social_medi.php?page=allhttp://www.cjr.org/the_news_frontier/best_practices_for_social_medi.php?page=allhttp://www.cjr.org/the_news_frontier/best_practices_for_social_medi.php?page=allhttp://www.cjr.org/the_news_frontier/best_practices_for_social_medi.php?page=allhttp://www.cjr.org/behind_the_news/eruption_interrupted.php?page=allhttp://www.cjr.org/behind_the_news/eruption_interrupted.php?page=allhttp://www.cjr.org/behind_the_news/eruption_interrupted.php?page=allhttp://www.cjr.org/behind_the_news/eruption_interrupted.php?page=allhttp://www.cjr.org/behind_the_news/eruption_interrupted.php?page=allhttp://www.cjr.org/behind_the_news/eruption_interrupted.php?page=allhttp://www.regrettheerror.com/2011/01/08/npr-reuters-cnn-and-other-major-news-orgs-incorrectly-declare-death-of-rep-giffords/http://www.regrettheerror.com/2011/01/08/npr-reuters-cnn-and-other-major-news-orgs-incorrectly-declare-death-of-rep-giffords/http://www.regrettheerror.com/2011/01/08/npr-reuters-cnn-and-other-major-news-orgs-incorrectly-declare-death-of-rep-giffords/http://www.regrettheerror.com/2011/01/08/npr-reuters-cnn-and-other-major-news-orgs-incorrectly-declare-death-of-rep-giffords/http://www.regrettheerror.com/2011/01/08/npr-reuters-cnn-and-other-major-news-orgs-incorrectly-declare-death-of-rep-giffords/http://www.regrettheerror.com/2011/01/08/npr-reuters-cnn-and-other-major-news-orgs-incorrectly-declare-death-of-rep-giffords/http://www.regrettheerror.com/2011/01/08/npr-reuters-cnn-and-other-major-news-orgs-incorrectly-declare-death-of-rep-giffords/http://www.regrettheerror.com/2011/01/08/npr-reuters-cnn-and-other-major-news-orgs-incorrectly-declare-death-of-rep-giffords/

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Prevention

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* * ** ** ** *

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PATIENT HAS CONFIRMED

IDENTITY

SITE

PROCEDURE

CONSENT

SITE MARKED/NOT APPLICABLE

ANAESTHESIA SAFETY CHECK COMPLETED

PULSE OXIMETER ON PATIENT AND FUNCTIONING

DOES PATIENT HAVE A:

KNOWN ALLERGY?

NO

YES

DIFFICULT AIRWAY/ASPIRATION RISK?

NO

YES, AND EQUIPMENT/ASSISTANCE AVAILABLE

RISK OF >500ML BLOOD LOSS

(7ML/KG IN CHILDREN)?

NO

YES, AND ADEQUATE INTRAVENOUS ACCESSAND FLUIDS PLANNED

NURSE VERBALLY CONFIRMS WITH THE

TEAM:

THE NAME OF THE PROCEDURE RECORDED

THAT INSTRUMENT, SPONGE AND NEEDLE

COUNTS ARE CORRECT (OR NOT

APPLICABLE)

HOW THE SPECIMEN IS LABELLED

(INCLUDING PATIENT NAME)

WHETHER THERE ARE ANY EQUIPMENT

PROBLEMS TO BE ADDRESSED

SURGEON, ANAESTHESIA PROFESSIONAL

AND NURSE REVIEW THE KEY CONCERNS

FOR RECOVERY AND MANAGEMENT

OF THIS PATIENT

SIGN IN

CONFIRM ALL TEAM MEMBERS HAVE

INTRODUCED THEMSELVES BY NAME AND

ROLE

SURGEON, ANAESTHESIA PROFESSIONAL

AND NURSE VERBALLY CONFIRM

PATIENT

SITE

PROCEDURE

ANTICIPATED CRITICAL EVENTS

SURGEON REVIEWS: WHAT ARE THE

CRITICAL OR UNEXPECTED STEPS,

OPERATIVE DURATION, ANTICIPATED

BLOOD LOSS?

ANAESTHESIA TEAM REVIEWS: ARE THERE

ANY PATIENT-SPECIFIC CONCERNS?

NURSING TEAM REVIEWS: HAS STERILITY

(INCLUDING INDICATOR RESULTS) BEEN

CONFIRMED? ARE THERE EQUIPMENT

ISSUES OR ANY CONCERNS?

HAS ANTIBIOTIC PROPHYLAXIS BEEN GIVENWITHIN THE LAST 60 MINUTES?

YES

NOT APPLICABLE

IS ESSENTIAL IMAGING DISPLAYED?

YES

NOT APPLICABLE

TIME OUT SIGN OUT

Before induction of anaesthesia Before skin incision Before patient leaves operating room

SURGICAL SAFETY CHECKLIST (FIRST EDITION)

THIS CHECKLIST IS NOT INTENDED TO BE COMPREHENSIVE. ADDITIONS AND MODIFICATIONS TO FIT LOCAL PRACTICE ARE ENCOURAGED.

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WHO surgical safety checklisthelped reduce inpatient deathsfollowing operations by 40percent -- New England Journal of

Medicine

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Why?

Remove reliance on memory

Prevent distraction Central collection point Introduce repeatable, measurable process

Create discipline (force) necessary for highperformance

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Tips

Increase font size while reviewing workAsk to spell name/title Keep research in separate font, color from

your writing

Keep items TK or to check in yet anothercolor

5-minute rule