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A simple tactic to mitigate errors
  1. Michael Chen
  1. Neurological Sciences, Rush University Medical Center, Chicago, Illinois, USA
  1. Correspondence to Dr Michael Chen, Neurological Sciences, Rush University Medical Center, Chicago, Illinois, USA; Michael_Chen{at}

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No matter how much patients may trust their physician, they still deal with much fear before a neurointerventional procedure. Mostly, they fear neurologic complications, which are among the most severe and devastating in all of medicine.1

The high level of complexity inherent to neurointerventional procedures raises this risk. Patient comorbidities, unexpected findings, unfamiliar devices, challenging vascular anatomy/pathology, and poor visualization can all sabotage even the most thoughtful plans. Furthermore, a multitude of providers are involved with the care of each patient including anesthesiologists, nurse anesthetists, radiology technologists, nurses, fellows and residents. Often, the level of engagement and understanding among all these people is surprisingly low. One survey of 300 surgical staff members in a Boston hospital revealed that one in eight of the staff members did not know where the incision would be until the operation started.2

To make matters worse, there are mundane distractions that add to these risks. During the procedure, we often field urgent and emergent consultations and may be thinking of how to manage these other patients, scheduling and prioritization. Industry vendors may be present during the case who may be another source of distraction with their incentives and influence. To make matters worse, even among experienced physicians, human memory and concentration is fallible, particularly when unexpected events occur, and remembering all the different management options on the spot may be …

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  • Contributors I am the sole contributor.

  • Funding The author has not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Provenance and peer review Commissioned; internally peer reviewed.