Perioperative Safety: Engage, Integrate, Empower, Sustain to Eliminate Patient Safety Events

Unlabelled: The perioperative environment is one of the most complex areas within a hospital with significant safety risks. Despite a long history of safety-focused work, a recent cluster of patient safety events prompted a renewed comprehensive approach to improve safety processes and transform culture. Methods: Our team comprehensively approached perioperative safety through integration across traditional silos and a focus on institutional safety culture. This approach consisted of a careful review of all events, developing Perioperative Safety Coordinating and Education teams, testing and implementing new/revised safety processes, and an ongoing evaluation plan. Results: Updates to our Perioperative Safety Mission and Tenets and the development of an empowered Safety Culture Champion team composed of a diverse group of frontline team members addressed our safety culture. In addition, key safety processes (time-outs, intraoperative huddles, and prevention of retained foreign bodies) were revised and implemented. Observation of key safety processes demonstrates a 90% compliance, which includes all steps and team engagement. After implementation, a span of 377 days between events was accomplished, which is significantly higher than the 33 days between events during our cluster. Conclusions: This work builds upon prior incremental improvements through a comprehensive investment in not only improving key processes but transforming the safety culture. Acceptable deviance from th