Preventing Surgical Errors: Effective Strategies Over Warning Signs in Operating Rooms

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This is a Chat GPT / Dall-E generated image:

It's silly, right? I've never seen a sign like this in an operating room. And I'm not advocating for them. It's not the right approach for quality and patient safety.

If warning signs actually prevented mistakes, and given that a vast majority of mistakes are caused by human factors (like fatigue) and systemic factors (like being behind schedule because instruments were delivered late to the O.R.)…

1) A sign like this would be posted in every operating room

and

2) Wrong-site, wrong-side, and wrong-patient surgeries would never occur

But, of course, it's not that simple.

What works?

Mistake-proofing works.

That includes methods like the “Universal Protocol,” including pre-op timeouts and checks. Checklists help.

And a culture of high Psychological Safety where anybody can speak up with a concern without fear of negative consequences.

But those methods and cultures are, sadly, far from “universal.” And surgical errors and mixups are far too common.

More broadly, why do organizations rely on warning signs, including messages that say things like “caution,” “please remember,” and “don't forget”??

Please join the conversation about this topic on Linkedin.

Also, please check out my new mistake-proofing course that's available through Karen Martin's TKMG Academy.


Please scroll down (or click) to post a comment. Connect with me on LinkedIn.
Let’s work together to build a culture of continuous improvement and psychological safety. If you're a leader looking to create lasting change—not just projects—I help organizations:

  • Engage people at all levels in sustainable improvement
  • Shift from fear of mistakes to learning from them
  • Apply Lean thinking in practical, people-centered ways

Interested in coaching or a keynote talk? Let’s start a conversation.

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Mark Graban
Mark Graban is an internationally-recognized consultant, author, and professional speaker, and podcaster with experience in healthcare, manufacturing, and startups. Mark's latest book is The Mistakes That Make Us: Cultivating a Culture of Learning and Innovation, a recipient of the Shingo Publication Award. He is also the author of Measures of Success: React Less, Lead Better, Improve More, Lean Hospitals and Healthcare Kaizen, and the anthology Practicing Lean, previous Shingo recipients. Mark is also a Senior Advisor to the technology company KaiNexus.

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