For Physicians at Banner Gateway Medical Center  

Safe Surgery Implementation – Never Means Never Initiative


Because your patients deserve the very best, Banner is revising the Safe Surgery Process model. The Safe Surgery Process is the standard of practice, based on research and best practice principles regarding correct site, patient surgery and counting of surgical supplies.

What’s New? The “Never Means Never Initiative.”
We’re implementing:

  1. The Safe Surgery Process to prevent wrong surgery and
  2. The No Thing Left Behind - Count Process to prevent unintentionally retained foreign objects following surgery.

Why? You and your patients deserve best practice.  We intend to eliminate wrong surgery and unintentionally retained foreign objects at Banner. 

Evidence:  At the University of Minnesota Medical Center, Fairview and at Christiana Care Health System, the count process eliminated ALL unintentionally retained foreign objects for four years. In 2009 the University of Minnesota Medical Center, Fairview, added the Safe Surgery Process eliminating wrong site, wrong procedure and wrong patient surgeries - zero retained foreign objects, zero wrong site/side/ procedure/patient surgeries. You, your peers, and your patients expect the best care and with this simplified process we’re confident the results can be duplicated.

What is it?
These processes are designed to cognitively engage team members in delivering safe patient care. They are the standard of practice, based on research and best practice principles to ensure that patients receive the correct procedure at the correct site and ensure that counted items are not retained following surgery.

Why should I do this?
When done consistently, this process will eliminate wrong site/side/procedure/patient surgeries and eliminate foreign objects left behind.   In 2010 Banner patients experienced 12 wrong site/side/procedure/patient or retained foreign object incidents.    While within the national averages, one wrong procedure is too many when we can reach zero!

How does it affect you?
The steps impacting you in Pre-Op:

Surgeon—in Pre-Op
1. Identify the patient in Pre-Op by checking the patient’s name and DOB on the patient’s ID band.

  • If you feel “odd” checking the ID band of a patient you know, you might frame it this way: “I’m checking your ID band to make sure it’s correct.”

2. BEFORE marking the site you will:

  • Check the physician’s order to verify procedure, site, and levels (if there are levels)
  • Check the informed consent form for the procedure, site, and levels (if there are levels).
  • Ask the patient or patient’s representative to verify the procedure, site, and levels (if there are levels).
  • Check the image, as appropriate, to confirm the procedure, site, and levels (if there are levels).
  • Resolve any discrepancies before marking the site.
  • Use an indelible marker to initial the surgical site at point of incision. 
  • Your initials must be seen after prepping and draping.

3. Mark the surgical site (using your initials) if the:

  • Site involves laterality (or levels) or the
  • Procedure is bilateral (e.g., bilateral knee replacement).

If it is not possible to mark the surgical site (e.g., teeth; oophorectomy with vaginal approach), then you will mark the site on an anatomical diagram.  The diagram will accompany the patient to the OR.

Anesthesiologist/CRNA—in Pre-Op

1. Patient Identification

  • Name with spelling
  • Date of birth

IF you move the patient to the OR check informed consent form and view the site marking to confirm the surgical site marking is correct.

**If site is NOT marked on patient’s body, confirm the correct site marking by checking the informed consent and surgical site marking on the anatomical diagram.

3. IF discrepancy, resolve prior to moving forward.

The steps impacting you in the OR:
1. Brief:
  This should occur when all members of the surgical team are in the room and before the final positioning of the patient.  It’s your chance to meet or greet your team and to validate the case plan.  Do you have what you need for a smooth case?  A successful briefing has been shown to reduce interruptions during the case.

2. Time Out:  (An orange Time Out towel will be used as a memory trigger for the team)

  • Surgeon:  “Let’s do the Time Out”
  • Circulator reads from the Consent the patient’s name, checks the armband (name/DOB) and procedure
  • Anesthesia Provider reads the patient name, a short hand version of the procedure and the antibiotic information from the anesthesia record
  • Scrub provides the site marking and verifies he/she is set up for procedure
  • Surgeon states patient’s name, complete name of procedure and site.

The Time Out is designed to cognitively engage ALL team members to help prevent error during the case and is formally structured with a specific order to decrease variability and assign roles of responsibility to the team. It ensures correct patient, correct site and correct procedure only.

3. Count:  (Please see the OR count policy for complete details on the count process.)

  • If a count is interrupted the circulating nurse and scrub performing the count must recount the interrupted category of items.  Do not interrupt the scrub and circulating nurse when they are counting—unless it is an emergency—because they will need to repeat the count.  This will prolong the case in the OR.
  • Counted items should not be cut or altered in any way. If a counted item is cut or altered in any way all parts of the item must be documented on the white board and removed from the field.
  • Place only x-ray detectable (radiopaque) sponges in the wound.
  • In addition to the baseline count, a count will also occur when closing a cavity within a cavity, at the start of closing the first layer, and at the start of closing the final layer (usually skin).
  • Throat Packs—Whenever a throat pack is placed in or removed from a patient, the person placing or removing the throat pack verbally announces the action so that the time in and time out can be correctly documented on the white board.
  • Placed sponges—When you place a sponge in the surgical cavity you will announce this to the scrub and circulating nurse so the circulating nurse can correctly document this on the white board.  You will also tell the circulating nurse and scrub when you remove the placed sponge(s) so the circulating nurse can document the placed sponge(s)’ removal on the white board.
  • Counts Not Done Due to Life-Threatening Emergency Situation. 
    -- If counts cannot be carried out because of life-threatening emergency situations this must be noted on the Operative Report and an Event Report must be completed.
    -- If the wound is closed, the patient must be x-rayed before leaving the room, if the patient’s condition permits.
  • A separate count must also be conducted:
    -- At the time of permanent relief of the circulating nurse.
    -- When multiple procedures involving multiple sites are performed. All counted items must be kept in the OR until all procedures are completed. 
    -- Anytime a team member has concerns about the accuracy of the count.
  • If the closing count is incorrect, the following steps are taken:
    -- You will be notified immediately.
    -- A recount must be conducted.
    -- If the item is still missing after the recount, you must search the wound and the scrub team must search the drapes, field, Mayo stand, and the back table. At the same time, the circulating nurse must search the sponge count bags, trash, linen, floor, and all items that have been counted off the field.
    -- If the item is located in this search, a complete recount must be conducted and the correct count documented.
    v If the item is not located in this search the circulating nurse must call for an X-ray.  A radiologist must read the X-ray while the patient remains in the OR.

L & D nurses will be required to count sponges and instruments on all vaginal deliveries as well. Two people are required to count the items together, so you may be required to count with the nurse during deliveries. Please see the L&D vaginal delivery count policy for more detail.

4. Debrief: Lead by the Surgeon.Record estimated blood Loss, pathology instructions, special patient considerations and any changes for your preference card.

BGMC Go-Live dates
Main OR & L&D OR rooms – May 9-13, 2011
We will have corporate leadership and surgeon champions available in the OR to support you in this new process.

How can I learn more about this process?
Video: A video is available that demonstrates the process. It will be shown in the physician lounge.

Train with the Staff: We invite you to attend the new process training with our staff.  We will be posting flyers throughout the OR indicating the dates and times for staff training.

Schedule a 1-on-1 training: You may contact Karen Salas, Director of Medical Staff Services at 480-543-2600, if you would like to schedule a specific time for yourself or a medical group to go through the new process orientation. 

Your help is appreciated to move Banner to ZERO.

Banner Gateway Medical Center
Higley Road and US 60
1900 N. Higley Road
Gilbert, Arizona 85234
(480) 543-2000
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