Terrence Loftus1, Deb Dahl2, Bridget OHare2, Karlene Power3, Yvette Toledo-Katsenes2, Ryan Hutchison2, David Jacofsky4, Kathleen Harder5. 1. Division of Care Management, Banner Health, Phoenix, AZ. Electronic address: tloftus@cox.net. 2. Division of Care Management, Banner Health, Phoenix, AZ. 3. Perioperative Services, Banner Health, Phoenix, AZ. 4. The CORE Institute, Phoenix, AZ. 5. Center for Design in Health, University of Minnesota, Minneapolis, MN.
Abstract
BACKGROUND: Patient safety in the perioperative period is essential for delivery of quality patient care. Mainstream quality organizations have implemented safe surgery recommended practices for ensuring patient safety. Effectively implementing safe surgery practices should result in a reduction in serious reportable event (SRE) rates. STUDY DESIGN: This retrospective cohort study compared results before and after implementation of a standardized safe surgery program across a large health care system. Observational audits were performed to assure adoption of the new process. Serious reportable event rates (retained surgical item, wrong site, wrong patient, and wrong procedure) were tracked. Statistical analyses were performed on the SRE rate and days between SREs. RESULTS: A total of 683,193 cases in the operating room and labor and delivery were evaluated over a 4-year period. The SRE rate before implementation was 0.075/1,000 cases and after implementation was 0.037/1,000 cases. There was a 52% reduction in the SRE rate (p < 0.05). The mean time between SREs increased from 27.4 days to 60.6 days (p < 0.05). Robotic and nonrobotic cases were affected equally; however, a significant difference in SRE rate persisted between robotic and non-robotic cases (p < 0.05). Robotic cases are 7 times more likely to incur an SRE. Audits demonstrated that the compliance rates for the program improved to 96% after complete system implementation. CONCLUSIONS: An effectively implemented standardized safe surgery program results in a significant reduction in SREs. Robotic cases are at high risk for an SRE.
BACKGROUND:Patient safety in the perioperative period is essential for delivery of quality patient care. Mainstream quality organizations have implemented safe surgery recommended practices for ensuring patient safety. Effectively implementing safe surgery practices should result in a reduction in serious reportable event (SRE) rates. STUDY DESIGN: This retrospective cohort study compared results before and after implementation of a standardized safe surgery program across a large health care system. Observational audits were performed to assure adoption of the new process. Serious reportable event rates (retained surgical item, wrong site, wrong patient, and wrong procedure) were tracked. Statistical analyses were performed on the SRE rate and days between SREs. RESULTS: A total of 683,193 cases in the operating room and labor and delivery were evaluated over a 4-year period. The SRE rate before implementation was 0.075/1,000 cases and after implementation was 0.037/1,000 cases. There was a 52% reduction in the SRE rate (p < 0.05). The mean time between SREs increased from 27.4 days to 60.6 days (p < 0.05). Robotic and nonrobotic cases were affected equally; however, a significant difference in SRE rate persisted between robotic and non-robotic cases (p < 0.05). Robotic cases are 7 times more likely to incur an SRE. Audits demonstrated that the compliance rates for the program improved to 96% after complete system implementation. CONCLUSIONS: An effectively implemented standardized safe surgery program results in a significant reduction in SREs. Robotic cases are at high risk for an SRE.
Authors: Ken Catchpole; Colby Perkins; Catherine Bresee; M Jonathon Solnik; Benjamin Sherman; John Fritch; Bruno Gross; Samantha Jagannathan; Niv Hakami-Majd; Raymund Avenido; Jennifer T Anger Journal: Surg Endosc Date: 2015-12-16 Impact factor: 4.584