MP06-20 SIGNIFICANT REDUCTION OF PERIOPERATIVE SERIOUS REPORTABLE EVENTS THROUGH A NOVEL SURGICAL SAFETY CHECKLIST AND TIME-OUT PROCEDURE

Abstract

You have accessJournal of UrologyCME1 Apr 2023MP06-20 SIGNIFICANT REDUCTION OF PERIOPERATIVE SERIOUS REPORTABLE EVENTS THROUGH A NOVEL SURGICAL SAFETY CHECKLIST AND TIME-OUT PROCEDURE Nicole Alavi-Dunn, Amy Murray, Ella Echavez, Michael Ander, Kevin Smith, Vrusha Shastri, Anne Murphy, and Christopher Gonzalez Nicole Alavi-DunnNicole Alavi-Dunn More articles by this author , Amy MurrayAmy Murray More articles by this author , Ella EchavezElla Echavez More articles by this author , Michael AnderMichael Ander More articles by this author , Kevin SmithKevin Smith More articles by this author , Vrusha ShastriVrusha Shastri More articles by this author , Anne MurphyAnne Murphy More articles by this author , and Christopher GonzalezChristopher Gonzalez More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003217.20AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: The Loyola University Medical Centertab is an academic quaternary medical center in a large metropolitan area which saw a significant increase in serious reportable events (SRE) during calendar year (CY) 2021. SREs are defined by the National Quality Forum; those relating to the operating room (OR) include wrong site, wrong procedure, wrong patient, OR fire, and retained foreign object (RFO). We describe an interprofessional and multidisciplinary effort which resulted in a novel surgical safety checklist (SSC) and robust time-out procedure to reduce SREs. METHODS: Action plans from root cause analyses of OR SREs and assessment of near misses led to the development of a perioperative safety steering committee. Anesthesiology, Nursing, and Surgery departments participated, which included all faculty, residents, fellows, advanced practice nurses, and staff. The team developed a new time-out process incorporating visual aids to improve SSC adherence. SSC comprises 1) pre-induction check-in, 2) time out prior to start of case, 3) check out (debrief) prior to closure. Checklist compliance was routinely audited. Tri-annual interprofessional and multidisciplinary conferences and instructional sessions were held. Education included the importance of reporting near misses, safety related incidents, behavioral issues; and audit compliance with serious safety event (SSE) and SRE prevention. OR safety event and near miss reporting was tracked. RESULTS: In CY 2021 19,713 total cases were performed at the main OR (13,248) and the ambulatory surgery center (ASC) (6,465). Ten SREs occurred: 5 wrong site surgeries, 2 OR fires, 2 wrong procedures, and 1 air embolism. The new SSC/time-out procedure was implemented in early January of 2022. In CY 2022 through September 14, 275 cases were performed at main OR (9664) and ASC (4611). Two safety events occurred: one SRE (wrong site anesthesia block), and one SSE (intentionally RFO which was identified before leaving the operating room yet required re-exploration). CY 2021 perioperative near miss reports were 534, compared to 425 for CY 2022 through September. CY 2021 incident reporting events were 1301, which increased to 1893 for CY 2022 through September. CONCLUSIONS: Implementation and compliance with a surgical safety checklist/time-out procedure, regular interprofessional and multidisciplinary meetings for education and compliance updates, and increased safety incident reporting decreased SREs by 80% over a nine-month period. Source of Funding: None © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e61 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Nicole Alavi-Dunn More articles by this author Amy Murray More articles by this author Ella Echavez More articles by this author Michael Ander More articles by this author Kevin Smith More articles by this author Vrusha Shastri More articles by this author Anne Murphy More articles by this author Christopher Gonzalez More articles by this author Expand All Advertisement PDF downloadLoading ...