ABSTRACT
The National Transportation Safety Board’s (NTSB’s) vice chair, Robert L. Sumwalt, summarized the NTSB’s findings in over thirty years of accident investigations. “The safest carriers have more effectively committed themselves to controlling the risks that may arise from mechanical or organizational failures, environmental conditions and human error.”2 Most important, we used FMEA (failure mode effects analysis) to help lead the culture change in the operating room (OR).
