OR Excellence Awards: Patient Safety: Team Engagement Is Key to Providing Outstanding Care


Having a common goal to provide an optimal surgical outcome is what sets the perioperative staff apart at the Ambulatory Surgical Pavilion (ASP) at Robert Wood Johnson University Hospital.

The perioperative team at the Ambulatory Surgical Pavilion (ASP) at Robert Wood Johnson University Hospital in New Brunswick, N.J., is always striving to do their best. The OR staff’s dedication to patient safety is clear based on their evidence-based practice initiatives, their continuous work surrounding different performance improvement (PI) projects and their participation in numerous hospital and unit committees. Because of this, the high-volume, multispecialty facility, which features four operating rooms, one procedure room and a 13-bed pre- and post-operative area, is this year’s winner of the OR Excellence Award in the Patient Safety category.

Among the many safety-focused measures the team employs, nurses developed a hand-off checklist tool to ensure every patient’s safety and readiness prior to going to the operating room. “The hand-off process begins when an OR nurse is ready to receive a patient from the pre-op area,” says Director of Nursing Rowena Lim, DNP, MBA, RN. “The OR nurse will get a verbal report from the pre-op nurse at the patient’s bedside once she has verified all the indicators listed in the safe surgery checklist tool.” The pre-op and OR nurse must go through 15 items on the checklist, some of which include patient identifiers, allergies, surgical procedure consent, anesthesia consent, pre-op medications, well as the presence of any bruises or wounds and jewelry or body piercings. “For each indicator, the OR nurse can check Yes, No, or N/A and can also add their own notes to the Result(s) and Comments boxes. When the checklist is complete, the OR nurse will bring the patient to the designated operating room,” Dr. Lim says.

As a result, staff receives glowing patient reviews. “Everyone was kind, professional and very clear as what to expect from my procedure. I felt safe as everyone checked my name band and DOB and addressed me to double-check. Thank you to all the staff for being fabulous,” wrote one satisfied patient.

Honorable Mention
Silly Song Makes Safety Stick
STOP, COLLABORATE AND LISTEN The daily safety huddles at Lakeside Surgery Center start with a catchy jingle.

A daily safety huddle is a great tactic to help your staff stay informed and prevent sentinel events. But how do you make sure your team is engaged and actively listening every single day? At Lakeside Surgery Center in Omaha, Neb., Charge Nurse Louise Bergeron, RN, enlisted the help of her husband.

“When we started the safety huddles, I jokingly said to my husband, a musician, one night, ‘Hey, you should write us a safety huddle song that I can play at the beginning of every safety huddle to help get everybody engaged,” recalls Ms. Bergeron. While strumming on his guitar, he created a 35-second Safety Huddle jingle. “He asked me what we talk about in these meetings, so I gave him a few key terms to include like ‘name alerts,’ ‘equipment issues’ and ‘infectious diseases.’ He threw the terms into a catchy song, even though he didn’t really understand what some of it meant,” she says.

Ms. Bergeron plays the song over a mini speaker located at the nurses’ station. “I’ve tried to hold the safety huddle without playing the song, and the team tells me they want to hear it,” she says. “It’s a great way to kick off the huddle with a little laughter.”

The huddles are usually held around 1:30 p.m. so perioperative staff can review the day up to that point — including any safety concerns that arose — and discuss the next day’s schedule. “We look at our patients for the following day to see if they have any special safety needs or if there are any potential issues we should be aware of. For example, do any of our patients require an interpreter or have the same first name?” The huddles typically last around 15 minutes, but Ms. Bergeron says it all depends on what safety concerns need to be addressed, as the team never hurries through something this important.

Angela Johnson, BSN, RN, director of nursing at the busy multi-specialty center, agrees that you can’t rush the daily safety huddle because it’s critically important. As she puts it: “Providing safe patient care is always our number-one priority.”

—Danielle Bouchat-Friedman

Auditing also plays a critical role. “The perioperative services quality coordinator observes a minimum of 15 cases per month to validate the teams’ compliance in providing safe surgery to all ambulatory surgical patients,” says Dr. Lim. The coordinator is armed with a comprehensive audit checklist during her random and unannounced visits. The team’s compliance is observed before the anesthesia induction, before the incision and/or before the procedure begins, and before the patient leaves the operating room and/or procedure room. “The audits show an incredible compliance rate of 100%,” boasts Dr. Lim.

The ASP team also makes participation in hospital committees such as the Hospital Shared Governance Practice Council, Magnet Ambassador Council, Falls Prevention Committee and Pain Management Committee a priority. “The beauty of it is our staff is very motivated and have one common goal: to provide an optimal surgical outcome for all our patients,” says Dr. Lim.

The Perioperative Services Quality coordinator observes a minimum of 15 cases per month to validate the teams’ compliance in providing safe surgery to all ambulatory surgical patients.
Rowena Lim, DNP, MBA, RN

Dr. Lim says most of the nurses at the facility have completed their undergraduate degree, with the exception of just two nurses with their associate degree. “Three of our nurses are planning to register for the master’s program this year and the two nurses with their associate degree have already registered for the undergraduate program.”

The staff’s total dedication to patient safety is evident in the numbers. “Since 2022, we have had no reported fall injuries, zero surgical site infections and our hand hygiene compliance is greater than 90%,” she says. “They know what they are doing really matters.” OSM

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