2024 IAPS Ambulatory Care/Surgery Facility Award Winner, Staff at Reading Hospital SurgiCenter at Spring Ridge, Tower Health

​Staff at Reading Hospital SurgiCenter at Spring Ridge
Tower Health​

According to The Joint Commission, wrong-side or -site surgery accounts for about 6% of all sentinel events reported in 2022; however, these statistics do not include near misses. The fast-paced environment of an ambulatory surgery center lends itself to creating opportunity for error. Recognizing this, the staff of the Reading Hospital SurgiCenter at Spring Ridge made it their mission to prevent future wrong-patient, -implant, -side, and -site surgery—and supplied a solution to a potential patient safety threat.

Quarterly audits were conducted on a variety of surgical specialties for staff to identify ways to decrease the chance for wrong-side or -site surgery. Audits include the pre-procedure verification, where the focus is on correctness of the consent and history and physical examination (H&P), in addition to surgical site identification and site marking. The second phase includes the operating room (OR) staff and the time-out (final pre-procedure pause). An average of 45 cases per quarter are observed and reported.

The findings revealed that patient identification, documentation verification, and site marking are completed without incident in preop. Findings from the OR revealed the staff were engaged during the time-out process, meaning all work stops except ventilation, and verbal acknowledgement occurred. The greatest area of concern noted from the audits involved surgeons: The results revealed physician engagement during the time-out process was at 83% (calendar year 2021). Knowing that there was the potential for a wrong-site surgery, staff ran with ideas on how to improve engagement. Staff were reeducated on the importance of all work stopping and focusing on the time-out. Administration empowered staff to speak up if they noted someone was distracted. Surgeons who did not properly perform the time-out were identified. Our results increased to 86% (CY 22).   

Staff next decided to do a deeper dive into the results. Additional questioning of staff found that during the time-out phase, surgeons were verbally acknowledging the specific patient information; the problem was getting the surgeon to stop what they were doing and give their undivided attention to the circulating nurse who was conducting the time-out. To combat this situation, staff decided they would have the surgical technician keep the back table away from the surgical field, thus creating an environment where the surgeon could be more engaged during the time-out process. Our current surgeon engagement rate sits at 92% (CY 23, quarters 1–3)."  

Throughout the patient encounter from scheduling until surgical start time, staff are responsible and empowered to speak up if they have a concern. Registration staff will seek clarification from the surgeon’s office when scheduling the case. Preop staff question the surgeon if the consent varies from the H&P. As an added safeguard, the patient participates in the process. Even when everything goes accordingly with pre-procedure verification and the time-out, mistakes can still occur. Staff stay vigilant in the OR when moving to different phases of the surgery.  

This project was staff driven and received full support from administration. Staff are awarded “Good Catches” when finding inconsistencies in the documentation, and their stories are shared with the unit. 

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