Patient Safety is No Accident

Purpose:
A formalized safety procedure and training system was implemented to improve quality, safety and enhance the efficiency of operations in the Operating Room. Training included a wide range of skills including communications, situational awareness, problem solving, decision making and teamwork.

Significance:
The burning platform for change was due to significant surgical events. Root Cause Analyses for events demonstrated intimidation of staff in OR as major contributors – staff afraid to speak up in the interest of safety. Teamwork was crippled by poor communication.

Strategy and Implementation:
Safety coaches worked with clinicians in perioperative services explaining the methodology, potential results, and why the effort would benefit all stakeholders. The“end user” adoption of culture changing behaviors and tools required effective leadership action. The approach included consideration of hospital philosophy, policy, procedure and practice. They developed standardized processes, hardwired tools and improved communication. Based on findings they prepared inter-disciplinary, experiential trainig providing evidence-based teamwork skill sets adapted to the needs of the OR. They developed customized safety tools (checklists, protocols, and scripts) to hardwire teamwork behaviors into daily work life. Clinicians met regularly to identify where improvements were needed, create the tools, and develop an implementation plan. Primary areas of focus included: Preop to OR/Anesthesia Handoff; Final Time Out; OR to PACU Handoff; Right supplies at right time and debrief and follow up.

Evaluation:
Survey results showed improvement in perception of patient safety indicators. Surgical events decreased from 5 in 2009 to 1 in 2011. Compliance with process measures for surgical patients improved. Perioperative staff turnover dropped below 5% for 2011.SSI infection rate decreased by 43% in 2011.

Implications for Practice:
Focus Group interviews revealed improvements including: more time to make sure the OR is prepared; greater collaboration between surgeons and staff; more effective use of time-outs and checklists; increased buy-in from physicians for formal safety initiatives.