Safe Surgery Project Report
In response to continued sentinel events related to wrong site procedure and unintended retained foreign objects at facilities within the Banner Health System, Banner Health’s corporate office initiated a system-wide Safe Surgery Project (SSP).
Since August, compliance of the new policies and practices has been measured at Banner Gateway’s Preop and Operating Rooms, Labor and Delivery OR, and Labor and Delivery rooms. A standardized audit tool is used and ten cases are reviewed monthly. Monthly data is compiled and reported to the facility CEO, CMO, CNO, Surgery, Anesthesia and WIS department chairs and DONs, the QM Director and the BH Corporate office. If 100% compliance is not met, the CMO, CEO, CNO, DONs and their managers will be held accountable for results in their facility. They are also accountable for implementing actions to support compliance. Audits are scored on a pass/fail basis; all audit elements must be compliant to pass.
August and September audits revealed opportunities for improvement. The following are consistent failure elements:
- Surgeons and anesthesiologists do not consistently identify their patients by using wrist bands in the Preop and OR settings.
- Scrubs need to release Raytecs/4x8s to fall to the sterile table during drop counts.
- Scrub and circulating nurse need to count out loud together.
- SSP information distribution to include medical staff, nurses, scrub techs. Education reinforcement will occur at shift reports, staff meetings and in Periop newsletter.
- Re-posting of Safe Site Surgery posters in ORs.
- SSP audit results will be shared with all involved staff.
If you would like a copy of the audit tool, please contact Medical Staff Services.