I AM Patient Safety 2020: Executive Director's Choice Award

2020 IAPS Executive Director's Choice Award Surgical Infection Reduction Team Winners Tyrone Reginal Health Network group pictur

Surgical Infection Reduction Team

Tyrone Hospital


In 2018, in response to ongoing struggles with an elevated rate of surgical site infections (SSIs), representatives from the OR, housekeeping, maintenance, infection control, and patient safety departments collaborated on a project to investigate possible causes and reduce SSIs for total joint replacement patients.

The infection rate was posted in the OR on a quarterly basis and discussed monthly at the patient safety and medical executive committee meetings. An apparent cause analysis was completed on every SSI, and policies and procedures were updated to match the most recent best practice data. When these efforts resulted in no improvements, and with no clear course of action, the Surgical Infection Reduction Team reached out to the Patient Safety Authority for guidance. The PSA assisted the team in completing a thorough assessment of the OR suite, which brought to light several deficiencies—things that had been overlooked every day because staff was used to seeing them.

Over several months, OR, housekeeping, and maintenance staff worked diligently to correct issues with terminal cleaning, broken equipment, and instrument cleaning practices. In addition to the environmental corrections, OR surgical care interventions were initiated, as well as staff interventions and patient education. The infection preventionist and patient safety officer made monthly rounds to monitor progress. When the PSA's infection preventionist returned after six months to reassess the OR suite, she noted a substantial amount of progress had been made. Through the efforts of this team, transparency with staff and physicians, and help from the Authority, the rate of surgical site infections for total hip arthroplasties was reduced from a max of 4.1% in 2018 to 0% in 2019. This multidisciplinary project improved surgical safety and made Tyrone Hospital an even better place to be a patient!


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