I AM Patient Safety 2020: Ambulatory Care/Surgery Award

2020 IAPS Ambulatiory Surgery Facukutues Award winners staff of Penn Highlands Elk Surgery Center group picture 


The staff of Penn Highlands Elk Surgery Center (PHESC) —  Molly L. Quesenberry, BSN, RN, patient safety officer; Kathy Wortman, BSN, RN, clinic administrator;  Dr. Brett Karlik, chief medical officer of the PHESC; staff of the Elk County Eye Clinic; Dr. J. Ryan Rice; and the staff of Penn Highlands Plastic and Reconstructive Surgery

Penn Highlands Elk Surgery Center

Staff at the Penn Highlands Elk Surgery Center launched a performance improvement (PI) project to further decrease the risk of a wrong-site surgery (WSS) by reducing the number of incorrect surgery registrations received by the physicians' practices during the initial pre-procedure verification.

Using data from the Pennsylvania Patient Safety Reporting System (PA-PSRS), the team analyzed event reports from the Center from calendar year 2018 and found that nine near miss events were related to incorrect registrations from four surgeons' offices. For each of these events, the surgeon and/or office manager was notified when the Center received incorrect registration information and it was reconciled either before patient admission or before the procedure.

In January 2019, the Center's patient safety officer (PSO) reached out to the physicians and offered to provide staff education on WSS prevention. The PSO developed a PowerPoint, “Partnering With the Surgeon's Office to Keep Our Patient's Safe," which includes information on WSS causes and prevention, 2019 Hospital National Patient Safety Goals from The Joint Commission, pre-op testing requirements for the Center, a newly introduced anticoagulation management form, and information on just culture. Patient Safety Authority handouts with tips to prevent a WSS also were distributed to physicians' practices.

As of December 2019, the data from the PA-PSRS indicated that this education was successful in decreasing the number of incorrect registrations by more than 75 to 100% of previous results, further decreasing the risk of a WSS. The goal of this PI project has been met.


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