Universal Protocol in Mohs Micrographic Surgery: Incorporating a "Time Out" Procedure in Histopathologic Interpretation
Tang, J.C..; Hanke, C.. W.
Journal of Drugs in Dermatology Jdd 19(2): 198
2020
ISSN/ISBN: 1545-9616 PMID: 32129971 Document Number: 18092
In 1999, the Institute of Medicine's (IOM) first report, "To Err Is Human", brought forth the issue of medical error in patient care.1 In this publication, the IOM recognized that mistakes or failures to prevent mistakes were mostly caused by flawed systems, processes, and conditions. It outlined a four-tiered approach to improve safety including: 1) development of leadership, research, tools, and protocols to enhance the knowledge base on safety, 2) a nationwide public mandatory reporting system and encouraging voluntary participation to identify and learn from errors, 3) oversight organizations, professional groups, health care purchasers to raise performance standards and expectations, and 4) implementation of safety systems in the healthcare organization to ensure delivery of safe practice. This was the first roadmap towards a safer health system.
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