Outpatient Surgery Magazine, providing current information on Surgical Services, Surgical Facility Administration, Outpatient Surgery News and Trends, OR Excellence and more.
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Authority (PSA). "We urge staff to work as a team and include the patient," he explains. "Though repeatedly asking patients the same questions can irritate them, the constant checks are necessary for error prevention. We need to include their under- standing of the procedure being performed." • Promote transparency. The proper reporting of wrong-site surgeries and near-misses is essential to raising awareness of issues that need to be addressed and learning from mistakes. It was a lack of communication regarding event reporting that initially fueled the creation of the PSA. Mr. Yonash says many facilities in the state didn't communicate openly and constructively about their errors and struggles. The Pennsylvania legislature sought to correct this issue in 2002 as part of the Medical Care Availability and Reduction of Error Act (MCARE). The legislature authorized the creation of the PSA, which is charged with receiving mandated error reports from facilities, analyzing the data and disseminating the information to help prevent future occurrences. "Pennsylvania was the first state to require the reporting of incidents that have the potential for patient harm, in addition to serious events," says Mr. Yonash. The objective of reporting involves documenting and acknowledging what led to these incidents as well as providing case studies to other cen- ters on how to prevent never events. It's promising that the rate of national self- reporting has increased in recent years. The Joint Commission says the percentage of self-reported sentinel events rose to 87% in 2017, compared with 62% in 2005, with 95 wrong-patient/site/procedure cases sub- mitted. The Joint Commission estimates that only 2% of all sentinel events are reported nationally. • Empower staff. In the past, UPMC Horizon and Jameson operating room nurses received the health system's Speak Up for Patient Safety Award for interven- ing to prevent wrong-site surgeries, and this year the sister hospitals were winners of this magazine's OR Excellence Award for Patient Safety. They deserve this recognition in more ways than one. Due diligence by staff and leadership in areas of certification, con- tinuing education and patient care have fostered a strong culture of patient safety. "If staff feel something isn't right or set up cor- rectly, they can call a condition stop and the sur- gery will not proceed until we resolve the issue," says Ms. Sebastian. Developing and maintaining a culture of safety was initially a challenge for UPMC Horizon, which acquired UPMC Jameson four years ago. Ms. Sebastian and her staff had to work to unite the two facilities. Standardization of wrong-site surgery pre- vention protocols helped create a solid foundation for the union of the two facilities. "Safety is our number one priority for any patient that comes through here for surgery," she says. Her staff are trained to advocate for patients during surgery who are incapable of advocating for themselves. Near-misses, which happen rarely, show UPMC's safety initiatives have worked correctly. Nurses don't hesitate to speak up if something is wrong. "There is a lot of staff involvement," says Ms. Sebastian. "Empower your staff to speak up and always stand behind them. Let them know that if they stop the line, they won't be punished. They need to know you're going to have their back." 3 0 • O U T P A T I E N T S U R G E R Y M A G A Z I N E • J A N U A R Y 2 0 2 1 CLICK TO CONFIRM Patient information and procedure details are entered into UPMC's electronic medical record for staff to reference at each step of the pre-op process. UPMC Jameson