Abstract
Surgery has a high potential for adverse outcomes. An error involving a retained retractor caused perioperative nurses at the University of Washington Medical Center, Seattle, to take another look at their department's patient safety practices and risk management procedures. Using another department's successful program as a model, the nurses considered the frameworks of risk management, quality improvement, and OR culture to develop a new patient safety quality improvement program for the OR. This article details the process of designing and implementing the program, which has energized staff members, enhanced teamwork, and resulted in improved patient outcomes.
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