OR Excellence Awards: Patient Safety & Quality: Just Do It!

A simple and unannounced change by OR team members achieved the safety improvements they knew it would.

No sentinel events spurred the change, but 2021 audits by the nurses and surgical technicians at The Reading Hospital SurgiCenter at Spring Ridge revealed that only 83% of surgeons at the eight-OR Wyomissing, Pa. facility were engaged during pre-surgical time outs.

The facility won the 2024 OR Excellence Award for Patient Safety & Quality for increasing that engagement to 86% in 2022, 94% in 2023 and 98% so far this year. They also won the award for the amazingly simply way they changed the behavior of the physicians: They moved the back table away from the sterile field.

That’s it. That’s the initiative.

It turns out the behaviors of the surgeons who were noncompliant weren’t acts of defiance. They were simply always ready to move on before the rest of the OR team, says Judy Bowman, MSN, RN, CAPA, the facility’s quality analyst/educator. They would say, “I agree, I agree,” during the time outs, but they were essentially multi-tasking — participating in the time out while preparing instruments on the back table by the operating table.

“Staff decided to keep the back table away from the surgical field during the time out, creating an environment for surgeons to be more engaged,” says Ms. Bowman.

That was all it took to solve the problem.

“It’s amazing how quickly we were able to change their behavior, whether they knew what we were doing or not, which really doesn’t matter,” adds Ms. Bowman. “What matters is we were able to change their behavior. And if it means we don’t give you the tools to start working, well, then it means we don’t give you the tools to start working.”

Since the change was made, Ms. Bowman isn’t aware of a single comment by any of the surgeons about the back tables no longer being accessible until after the time outs are conducted.

“I don’t know if they really noticed or not, but we simply moved the back table without telling them, so they obviously couldn’t handle any instrumentation until the time out was over,” she says.

Ms. Bowman suspects that because surgeons implicitly trust and rely on the staff — many of whom have many years of experience — they never even thought to question the change. Also, the change didn’t delay any cases. Whatever the surgeons used to do with the instruments during the time outs took seconds, not minutes, to do after the time out.

Kasie Moll, BSN, RN, CNOR, and Maria Barton, BSN, RN, CNOR, came up with the idea. Ms. Bowman says the fact that the solution was staff-driven is likely what made it a success. “Once we realized we had a surgeon-engagement issue, we took it back to the people who are actually at the point of impact to find a solution, and they did,” says Ms. Bowman.

The issue came to light after quarterly audits were conducted with a focus on preventing wrong surgeries. It turns out that the facility was doing well in most regards, and the surgeon-engagement issue was the only problem area.

Honorable Mention: Never Again

Revamped Storage of K-Wires to Ensure Correct Ones Are Used in Ortho Procedures

REARRANGED K-wires are now stored according to size and type on different shelves and in different colored bins to avoid confusion. | Cleveland Clinic Marymount ASC

When a routinely used item led to a serious event that impacted a patient’s outcome, the staff at Cleveland Clinic Marymount Ambulatory Surgery Center took immediate action to make sure it never happened again.

The event, which occurred at the Garfield Heights, Ohio, facility earlier this year, involved a device that was used during an orthopedic surgery. The preference card, from which the tools needed for each case are prepared, did not include the device for this case. After the surgeon said he needed it, a surgical technician obtained three of these devices and returned to the OR.

There are several sizes and two different textures for this device. While the size of the device was validated, the texture or type was not. The surgeon asked for the three devices to be opened, but the nurse dedicated to the room was involved in another task, so the surgical tech instructed an observing nurse to open them and bring them onto the sterile field. The standard operating procedure of verbally reading back the size and type of the device from the observing nurse to the surgical technician was not followed, which resulted in the incorrect device being used during the procedure.

The facility’s investigation included looking at where the devices were stored and labeled. The product numbers of these devices are nearly identical, and they were stored on the same shelf. As part of the action plan to ensure an event like this never happens again, devices are now in different colored bins with each type stored on different shelves.

Since the event, only the circulating nurse opens supplies and brings them to the field. Anyone deemed as an observer of a case is prohibited from doing so.

“Patient events or harm is never the intent of healthcare caregivers. Events make teams think differently and assess daily standards or practice,” says Kimberly Platt, MSN, RN, CAPA, director of nursing surgical services. “Since this event, several conversations have taken place for enhanced workflows and changes within the unit for improved standards. With the change in location and the addition of visual management, no events with these devices have occurred.”

—Adam Taylor

The facility also provides staff with annual Universal Protocol education and empowers them to speak up if they feel someone in the room is distracted. Ms. Bowman says the project emphasizes the importance of vigilance by everyone throughout the patient encounter.

“When we do the time out, the expectation is that everyone stops what they are doing,” she says. “Even though we’ve increased our engagement rate to 98%, we will continue to work on this. As the educator, I stress to all new staff and all new physicians that being engaged during the time out is not negotiable.”

When picking a quality improvement project, the facility always tries to focus on something it can control. This project certainly qualifies, as Ms. Bowman says that a well-run time out without shortcuts should result in zero wrong surgeries.

She’s happy, but not surprised, that the improvements were achieved without needing to make the project overly official, with a physician champion or a presentation to the facility’s board. “You have that in your back pocket if needed, but you hate to play that card immediately,” she says. “Sometimes I think people will dig their heels in harder when you go that route. This way, we just made the change, and it made a difference. We changed the surgeons’ environment, and it turns out they’re a product of that environment.” OSM

Honorable Mention: No Exceptions

Every Patient at Sonoran Crossing Now Goes From Pre-op to the OR After a Documented Handoff

HARD STOP Pre-op nurses are expected to complete all consent forms before every patient heads to the OR — and OR nurses can “tap them out” from a different pre-op bay to perform a handoff that confirms the information. | Sonoran Crossing Medical Center

Inconsistent handoff practices at Sonoran Crossing Medical Center (SCMC) in Phoenix led to patients leaving the pre-op area and arriving in the OR without being shaved properly, with no blood pressure cuffs on, unsigned anesthesia consents or incomplete history-and-physical updates.

These lapses were discovered after the patients were in the OR, resulting in a significant amount of case delays, so the team designed a new handoff sheet to ensure consent forms are completed and patients are prepped appropriately, says Dawn Border, BSN, RN, CCRN, a nursing supervisor at SCMC.

Pre-op and OR nurses were educated on the importance of the handoff and told the expectation is they will be performed before every case without exception. If a pre-op nurse is busy in another bay when an OR nurse comes to get a patient, the OR nurse now “taps out” the pre-op nurse from the bay to perform the handoff, which includes a review of all consents and the history/physical update to make sure they’re complete. The two nurses also confirm that the patient is marked for laterality prior to leaving pre-op.

“This is a hard stop for our staff to not go back to the operating room prior to having all documents signed and dated,” adds Ashley Taylor, RN, BSN, CNOR, director of perioperative services at SCMC. “Having two sets of eyes verifying all the documents and ensuring patients are going to the OR with the proper equipment allows the circulating nurse to focus on patient care.”

A weekly review of Midas reports in the six months since the new focus on handoffs showed there were only two issues surrounding consent reports, a significant decrease, and those situations were investigated and dealt with immediately. “If it is found that staff is not participating in the handoff, it is addressed in real time,” says Ms. Border. “We have found that by having staff take accountability, we have had great success.”

Ms. Taylor agrees, saying, “Our patients are our main focus and having checks and double checks help the families know that their loved one is being treated like our family and we would go to any length to ensure that patient safety is done accurately.”

—Adam Taylor