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Pronovost’s call to nursing action

Publish Date: 9/25/2013

3 OR safety challenges and 3 solutions

“Believe you are powerful enough to prevent harm and declare harm unacceptable—the goal must be zero harm.”

This is the message Peter Pronovost, MD, PhD, FCCM, hopes perioperative nurses take to heart in the health care community’s efforts to do a better job of protecting all patients from harm.

Pronovost advocates local identification of safety risks and evidence-based safety principles that can be translated into practice and then spread (with tailoring) for broader use. He advances this work as
 senior vice president for patient safety and quality and as director of the Armstrong Institute for Patient Safety and Quality for
Johns Hopkins Medicine.

Evidence-based principles are key drivers for change, but Pronovost says work to reduce patient harm must also be led by frontline clinicians (including nurses) working together and focused on culture—an approach known as CUSP (Comprehensive Unit-Based Safety Program). This approach has led to sustained reduction in ICU CLABSIs. Similar work through SUSP (Surgical Unit-Based Safety Program) is proving successful with reducing SSIs for colorectal surgical patients.

Beyond these successes, Pronovost acknowledges, “We don’t have a national success story to say here’s a harm and here’s how it is reduced.” He asks perioperative nurses to recognize their role in creating these success stories.

So, where to start?
Pronovost shares his top OR safety concerns and suggests collaborative solutions perioperative nurses can use to protect patients:

OR Safety Challenges

1. Lack of teamwork in the OR
There is still work to be done around creating an OR culture where everyone is respected and feels comfortable speaking up. Just the other day I heard about a situation where a surgeon demeaned a nurse in front of the team. It crushed the nurse. This kind of behavior is counterproductive to patient safety work. Consider the number of checklists in use around the country, yet wrong site surgeries are still on the rise.

2. Medical device dangers

The OR today is probably more dangerous than it was 30 years ago because we are using more and more sophisticated technology (including EMR), yet we often have lack of clarity around medical device training and competency.

Also, we are buying electronic OR equipment that doesn’t allow communication with other equipment, which creates extra work for nurses and doctors. This would be the equivalent of building an airplane without automated landing gear and relying on the airplane pilot to manually lower landing gear at the right time. As a result, our safety programs are built on the heroism of clinicians.

3. Lack of sufficient staffing levels

Too often I’ve seen reform efforts to control health care costs lead to paying hospitals less, which has resulted in staffing cuts at a time when workload is already high.

Quality improvement infrastructure is also being cut, which means cuts in time to learn from mistakes. Virtually no other industry would operate without an improvement infrastructure. By cutting this we have created more frustration because staff see something that is broken, but have no time to fix it.

Solutions to reduce perioperative patient harm:
1. Create a CUSP (Comprehensive Unit-Based Safety Program) team

Bring together frontline staff (with leadership support) to identify and reduce patient safety risks, while also learning about safety science and implementing teamwork tools.
Cull out principles and then modify to fit individual practice settings—95% of a safety tool or practice may be identical across ORs, but it’s that 5% difference that makes it work.
2. Create a way for CUSP teams to talk together

Create a structure where individual CUSP teams gather to learn from each other as a larger group, while maintaining individuality.
Our CUSP teams are shaped using a fractal organizational model (similar to leaves on a twig that may vary in size but maintain the same structure). At the department level we have a perioperative CUSP safety team, and within this team we have smaller CUSP teams for each perioperative product line. This creates the structure for peer learning at the department level, but also allows each group to work independently.
Within this structure we have defined core skills for safety leaders who must earn our certificate in patient safety. These skills include CUSP, teamwork, evidence-based practice, project management and leading change.
NOTE: Leading change is the key skill—to improve you have to get peers on board.
3. Look for innovations in other industries

  • Look to aviation, especially for teamwork training.
  • Look to the nuclear power industry as a model for peer-to-peer reviews.
  • Look to systems engineering for innovative approaches to integration and automation—this is particularly valuable in looking at medical device integration in the OR.
REMEMBER: Don’t make the mistake of directly applying principles from other industries—health care is unique.
Additional Resources

Learn more about developing a Surgical Unit-Based Safety Program (SUSP)

Follow Pronovost’s blog to keep up with patient safety innovations

Watch this video interview with Pronovost to learn about the work of the Armstrong Institute for Patient Safety and Quality

Guidelines for Perioperative Practice


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