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The Partnership for Patient Care announced its first initiative for 2008 as an improvement collaborative focused on eliminating wrong-site surgery in our region. A comprehensive program facilitated by ECRI Institute included education, technical assistance, tools, and an interactive forum to help hospitals implement apppropriate safeguards and interventions. The program was led by John Clarke, MD, Clinical Director for Patient Safety and Quality Initiatives at ECRI Institute, and a trauma surgeon acknowledged as the nation’s leading authority on wrong-site surgery.

Over 31 organizational teams attended the first workshop in March 2008 at the ECRI Institute. Dr. Clarke identified the key elements of prevention:

• assuring accurate documentation and patient consent;
• independent verification of the surgical site at each hand-off;
• appropriate site marking; and
• an effective “time out” prior to incision.

The workshop included an analysis of actual case studies reported to the Pennsylvania Patient Safety Authority. Participating teams prepared a baseline assessment of their practices and completed observations for a sample of 10 cases in the operating room. Three conference calls were held in April 2008, along with a final workshop in May 2008, that addressed implementation challenges, lessons learned, and preliminary program results. The program was rated “good” to “excellent” by 100% of the participants.

The participating teams completed a follow-up assessment of their practices that included post-program observational data from the operating room. Significant progress was demonstrated in strengthening patient safety, as evidenced by the 7.3% overall improvement in comparing aggregate follow-up to baseline scores during the three-month timeframe. A follow-up observational assessment showed the following:

  • a 12%-19% improvement in pre-operative verification;
  • a 5%-16% improvement in site marking practices;
  • an 8%-16% improvement in surgical "time-out" compliance.

    Click here to see the final report.