PeriOperative November 2016 Surgeons, nurses, surgical techs talk about patient safety.

November Theme of the Month - Safety Behavior Guidelines -

The Hospital of the University of Pennsylvania

See “Safety Guidelines” on page 12.

Perioperative staff are confronted with numerous occupational hazards on a daily basis that pose a risk of personal injury. An unsafe workplace contributes to staff and patient injuries that can result in physical and emotional difficulties. The PeriOp Safety Fellows and Carolyn Grous, Director of Perioperative Services, have created ‘Safety Behavior Guidelines’ to provide instruction on how to reduce, avoid, and handle safety hazards in the perioperative setting.

Do you have a safety concern?

Email safety1@uphs.upenn.edu or

contact the Safety Fellow on call

24/7 who can be found in Navicare.

“Our work is never so urgent, nor our schedule so important, that work cannot be performed safely. Error situations are predictable, manageable, and preventable.” -Limerick Nuclear Power Plant

‘Share Your Voice’ Feature Continues Wrapping up the Share Your Voice Campaign we hear from Surgeons, Nurses, and Surgical Technologists on their perceptions of safety, teamwork, and communication in Perioperative Services. See pages 2-11.

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“When a patient comes into our care, they know that we are going to be able to take whatever their problem is and get them through their healthcare encounter in a way that gets the best possible result for them and keeps them away from potential harm.”

-Sean Grady

What does patient safety mean to you?

“Creating an environment that sup-ports patient safety is consistent with the achievement of the best outcomes for our patients.”

-Ronald Fairman

“Our first mission as health care pro-viders is to do no harm. Too often patients are hurt due to medical mis-takes. Patient Safety is of utmost im-portance to eliminate avoidable or unintended harm.”

-Michael Acker

“Patient safety means interdisciplinary collaboration and collegiality to max-imize patient safety and satisfaction.”

-Jon Morris

“Patient safety means that my patient has an outcome that is free of medical errors.”

-Liza Wu

“Patient safety means securing the best possible care and outcome for any given patient who presents to the hospital for any form of care.”

-Benjamin Braslow

“What patient safety means to me is providing the environment where the patient feels that their well-being is at the center of everything, and that all efforts are made to make sure all steps in the patient care process result in the safest and best outcome.”

-Kim Olthoff

“Patient safety means getting everyone on board to improve patient outcomes in a non-confrontational way and really have team mem-bers buy into it.”

-Kristoffel Dumon

“Patient safety is the cornerstone for therapeu-tics. You have to make sure things are safe and appropriate before we can do anything that we would consider repairing or healing. That’s the first building block of the foundation and should be the first thing we think about.”

-Bruce Malkowicz

“Making sure everyone is working together to keep the patient safe.”

-Douglas Fraker

“Patient safety means in the hospital we’re looking out for all potential as-pects of the care that could result in detriment to the patient.”

-Peter Abt

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“The communication piece is the most im-portant part because there are so many people involved in the care of our patients and every-body has to be on the same page. Usually, I try to keep it very simple about what the patient is here for, what we intend to do, what the poten-tial problems may be and if they occur what we are going to do to ensure patient safety.”

-Sean Grady

How does teamwork and clear communication impact patient safety?

“Teamwork and clear, consistent com-munication is always in the best inter-est of our patients.”

-Ronald Fairman

“ One of the primary drivers of medi-cal mistakes is poor or inadequate communication. This is especially im-portant during times of handoffs in care. We must improve teamwork and communication to eliminate medical mistakes leading to patient harm.”

-Michael Acker

“In order to reduce medical errors and ensure patient safety, there must be open and good communication amongst all team members.”

-Liza Wu

“When the whole team has a game plan ahead of time and everybody is on the same page, outcomes are im-proved and overall efficiency is im-proved.”

-Benjamin Braslow

“Teamwork and communication are critical to patient safety in that each member of the team provides an important link or step so that noth-ing is missed and all details are known and communicated. In complex surgery, it is essen-tial that the right hand knows what the left hand is doing at all times, particularly when there are unique situations or the status of the patient is changing.”

-Kim Olthoff

“It’s important for team members to communi-cate what they know about the patient plan of care. If I don’t know what someone else within the team knows, it can lead to unsafe patient care, and I have seen this happen over and over again. This can lead to mistakes happening. I think teamwork and communication are the key to having those open channels in 2016. This allows us to make fewer mistakes on a daily basis.”

-Kristoffel Dumon

“Medicine has become really complex and it takes not one person but a team to put things together. Everybody has their individual roles. However, we also have to do it in a coordinate fashion by coordinating a lot of different talents if we are to provide safe and optimal care for our patients.”

-Bruce Malkowicz

“In teamwork everybody has to do their part for their role, yet keep the focus on what's right for the patient. Communication is key during the surgical time out. I always confirm CT Scans and biopsies as the primary source.”

-Douglas Fraker

“It’s vitally important that we have good teamwork and communication because this results in better care for the patient.”

-Peter Abt

“Team work and communication are vital for successful patient safety not only from nurses to medical students, to attending's all levels need to be on the same page to make sure a suc-cessful plan is executed to reduce er-rors and increase patient safety.”

-Ryan Borek

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“Making sure that the care of each patient is as perfect as possible in eve-ry aspect of their care.”

-Noel Williams

What does patient safety mean to you?

“It means to look out for patient well-being and caring for them in an appro-priate manner so they have the best possible outcome.”

-Stephan Kovach

“Not letting patients fall out of bed.”

-Benjamin Jackson

“Patient safety is making sure that eve-rybody on the team is putting the pa-tient first and working as a team.”

-Kristy Weber

“Patient safety is being a patient’s advo-cate. In the OR, after the patient goes to sleep they can't speak for themselves. I need to be the patient's voice.”

-Merrilee Martin

“Avoiding adverse outcomes by pro-tecting the patient from inevitable hu-man errors.”

-Daniel Dempsey

“Keeping patients safe and free from harm is the cornerstone of quality nursing care.”

-Rose McGrath

“Patient safety means everything to me. Our surgical patients fully trust us to advocate on their behalf. We are the eyes, ears, mouths, hands, and feet for our surgical patients. Losing control during surgery is very difficult, but knowing someone has your back makes all the difference in the world.”

-Romagnia Hill

“Patient safety means preparation! The assess-ment and interview process afford me the oppor-tunity to develop a plan of care that will prevent any harm to the patient.”

-Nora Taylor

“Patient safety encompasses one of the highest priorities in providing quality care for our pa-tients.”

-Judith Hoffman

“Patient safety means always putting your pa-tient first. With every patient encounter, I try to render the best care possible. I believe all of our nurses practice with these values which main-tains our steadfast commitment to a culture of safety.” -Karima Wilson

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“It’s ESSENTIAL! Makes patient safety possible. Have been in place in Bariatrics for many years.”

-Noel Williams

How does teamwork and clear communication impact patient safety?

“It makes sure their care is efficient. It makes everyone know exactly what the care plan is, and it makes the patient care seamless.”

-Stephen Kovach

“Making sure everyone is on the same page and knows all pertinent infor-mation about patients (like allergies).”

-Benjamin Jackson

“It is critical and means that everybody in the room from the brand new stu-dent to the most experienced person needs to speak out when they see something wrong. There should not be a hierarchy in terms of feeling com-fortable speaking out about safety.”

-Kristy Weber

“It takes a team effort to get every case done. Anesthesia, Surgery, and Nurs-ing all play a vital role in every case. The communication between all departments needs to start before the patient is even brought into the room.”

-Merrilee Martin

“Obviously no single person can pro-vide all the care. We need a team and you can’t have a team, or a high reliability organization for that mat-ter, without really, really good com-munication.”

-Daniel Dempsey

“Evidence supports that communication and other teamwork skills are critical in the preven-tion and mitigation of errors in patient care.”

-Rose McGrath

“Teamwork and clear communication result in one optimal patient care.”

-Romagnia Hill

“I prepare to keep my patient safe by communi-cating with the anesthesia and the surgical team so I have a clear understanding of their plan for the patient. As a team we work together to en-sure patient safety!”

-Nora Taylor

“I feel that teamwork and effective communica-tion among each team member, Anesthesiolo-gist, Surgeon and Nursing personnel is essen-tial.”

-Judith Hoffman

“Team work and clear communication are im-perative to maintaining a culture of safety. A perioperative team is comprised of subgroups that all share one common interest which is pa-tient safety. Every person has a vital role.”

-Karima Wilson

“Patient safety means everything to me. I’m a patient advocate and in order to give quality care I need to get infor-mation from the patient, the surgeons, pharmacy, whoever may be to make sure I don’t give drugs that may cause adverse effects.”

-Shawnte Christmas

What does patient safety mean to you?

“Surgery is a very big event in a pa-tient’s life. My job is to ensure their safety throughout the surgery maintain-ing a calm atmosphere, making sure the patient actually feels safe and comfort-able in the operating room.”

-Stephanie Angud

“Patient safety is more than just two words. It’s about protecting our pa-tients from errors, infections, acci-dents and much more. It’s my duty to advocate and protect the patient be-cause they can not protect themselves while they are asleep on our operating room table.”

-Kristen Tuma

“Patient safety means E-V-E-R-Y-T-H-I-N-G!”

-Maria Dowling

“Patient safety is 100% of what we do. Keeping our patient safe, whether it’s dealing with medications, seat-belt, allergies, any contraindications, the correct side of surgery. Utilize the five rights!”

-Robin Wesley

“Patient safety means patient advoca-cy and protocol/process adherence.”

-Tammi Britt

“Patient safety is the very core of what I believe nursing practice encompasses. It ranges from making certain that equipment is functional pri-or to use on a patient, to verifying medications against allergies, safe positioning, and every-thing in between those actions.”

-Martha Toney

“Patient safety is at the center of my nursing care. I treat every patient as if they were my family member, which is a good thing because I love my family.”

-Brittany Moshen

“Patient safety is verifying two different ways to make sure this is the correct patient and that we are doing the correct surgery. Patient should be identified for every handoff, during timeouts, and while entering and leaving the room.”

-Dan Pashley

“Patient safety means that all patients are cared for appropriately and have good outcomes.”

-Maria Campbell

“It means we do the best we can for our pa-tients, using what we’ve been taught as nurses and techs in the operating room. Maintaining their safety at all times.”

-Marlena Pellegrino

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“It can impact negatively or positive-ly. If done right we will have success-ful patient outcomes.”

-Shawnte Christmas

“Teamwork and clear communication has an huge impact on patient safety. All the team members need to be on the same page before the patient enter the room.”

-Stephanie Angud

“Though all of us in the OR have our own unique roles, as a team our ulti-mate goal is to keep our patients safe. Therefore, lack of communica-tion brings on avoidable stress.”

-Maria Dowling

“We all work as a team everyday so we’re all on the same page.”

-Robin Wesley

“Teamwork and clear communication allow for seamless patient flow and positive patient experiences through-out the perioperative process.”

-Tammi Britt

“Personal experience and fact-based evidence have proven that when there is clear communi-cation between team members who are taking care of a patient, with clear expectations of the outcomes, the chances of harm to the patient are decreased.”

-Martha Toney

“People perform better when everyone knows who is in their room, their role and what we are doing for the day. I try to facilitate a huddle each morning. It helps facilitate teamwork and open communication and do what is best for the patient.”

-Brittany Moshen

“Clear communication during handoff is very important. That is probably the number one mistake that happens. If you do not communi-cate clearly to the person relieving you, things can get lost.”

-Dan Pashley

“Better communication can help provide pa-tients safer outcomes so all the medical profes-sional are aware of patients needs and issues.”

-Maria Campbell

“Teamwork and communication is very im-portant because we collaborate with each other and we all need to be on the same page regard-ing the patient’s status. It provides a means for optimal patient care.”

-Marlena Pellegrino

How does teamwork and clear communication impact patient safety?

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“I have always believed in the nurs-ing philosophy of ‘first do no harm.’ Whenever I’m taking care of a pa-tient my goal is to create as little harm as possible.”

-Michael Ham

“Patient safety defines the parame-ters of our job.”

-Karen Leddy

“Patient safety is ensuring that eve-rything we are doing in our practice is in the best interest of patient.”

-Meggan Lee

“Patient safety is one of my top pri-orities for my patients! Patient safety to me is doing what is best for the patient, especially intra-Op when they may not be able to advocate for themselves.”

-Laura Clark

“Keeping my patients safe and mak-ing sure everything goes well during surgery.”

-Tyesha Pollard

“Patient safety guides all decisions. The quality of care and the safety of patients are core values we live by as nurses. Patients trust us to be their advocates and we have a moral re-sponsibility to protect and care for them It’s a discipline that we live by.”

-Keisha Webb

“Patient safety is the foundation of everything we do in healthcare. It means providing the best possible care to ensure the best outcome for patients and their families.”

-Danielle Mouradjian

“Patient safety means just that, keeping patients safe throughout their hospital experience, while providing the best possible care. This keeps pa-tients returning to our facilities and talking about what a great health system we have.”

-Linda Willis

“Patient’s treatment is based on the best possible care and results in the best outcome for the pa-tient.”

-Kaleen Tatlow

“Patient safety means that my patient has zero adverse events and that every patient makes it out of to the room just the way they came in.”

-Daniel Wilson

“Patient safety means to me that patients and their families are educated on post operative emergencies, recovery from anesthesia and are able to go home after surgery.”

-Elizabeth Corbett

What does patient safety mean to you?

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“Teamwork is vital to success, espe-cially in the PACU. When a patient comes out of surgery, we all work as a group. If there is an adverse event, we resolve it as a group.”

-Michael Ham

“Teamwork and clear communica-tion is vital to prevent errors. I think it would be a great idea to have brief-ings before each case with nursing, anesthesia and surgery.”

-Karen Leddy

“If everybody is on the same page, knows a clear plan for the patient and the patient needs, there should not be any mistakes. Effective com-munication leads to the best outcome for the patient.”

-Meggan Lee

“As nurses, and as health care provid-ers, we work together for what is best for the patient. Communicating clear-ly with our team helps reduce errors and increases the quality of patient care.”

-Laura Clark

“It’s not just one person who takes care of patients, it’s a team. Working together allows us to avoid loop holes, ensure our patients are safe and taken care of the proper way.”

-Tyesha Pollard

“Open and candid communication is a key component of safe and effective patient care. Clear expectations of all team members optimize efficiency and prevent errors or unexpected events.”

“Teamwork and collaboration create a culture in which bidirectional communication occurs to reduce or prevent medical errors. A respectful culture ensures everyone is able to speak up and contributes to improve patient safety.”

-Danielle Mouradjian

“Team work and communication have proven to be the number one factor in patient safety. In PeriOp, the handoff is a crucial part of what we do everyday.”

-Linda Willis

“It impacts patient safety hugely because team-work is essential and it is the basis for patient safety. Without teamwork, things may get lost in such a big system.”

-Kaleen Tatlow

“It helps patient safety when everyone is on the same page. You would know if there are any specific disorders or special needs. Everyone should collaborate together between Anesthe-sia, Surgery and Nursing to coordinate care.”

-Daniel Wilson

“Teamwork and communication is very im-portant because we all need to know and under-stand what the plan is for each and every pa-tient.”

-Elizabeth Corbett

How does teamwork and clear communication impact patient safety?

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-Keisha Webb

“Patient safety means to me advo-cating for my patients and ensuring the team participates in the bedside report.”

-Darin Monte

“Patient safety is very crucial. It is very important to the patient’s well-being and it should be a top priority. Safety is a top priority to me!”

-Jamela Harris Clayton

“Patient safety means being a great advocate for my patient.”

-Roland Williams

“Making sure every step is taken to ensure the patient’s safety, with no shortcuts, which can endanger the patient. Keeping a clear mind and focusing on the goal of surgery to avoid any confusion or errors.”

-Angel Escobar-Reyes

“Patient safety is a high priority on my list. I know how it feels to go un-der and wake up from anesthesia that’s why I go out of my way to pro-tect patients and help my team!”

-Rafeeq Rainey

“Patient safety is everything! Our commitment to this Hospital and to the patient is to make sure every pa-tient has a safe procedure, safe envi-ronment, and a safe recovery.”

-Malcolm Waddell

“Patient safety is quality care being provided to a patient.”

-Howard Davis

“Pretty much every decision you make in the OR you have to think of your patient’s best interests. From scrubbing your hands to in-specting your instruments, everything is done to ensure patient safety. That means having a good surgical conscience. If you contaminate something, do the right thing! There is a pa-tient under those drapes.”

-Brittany Cannon

“It means keeping the patient safe at all times no matter what the situation is. Their safety comes first, regardless if you are being rushed to do something or not. The patient is always first!”

-Lynne Satchell

“It is really making sure you come to work every single day focused and knowing patient safety is, above all else, what we are doing here. When I come to work that’s my main goal.”

-Amy Simpson

“To ensure patient safety, always maintain a sterile field to prevent hospital acquired infec-tions. Surgical Time Out should always be verified by patient’s consent form.”

-Grunderson Jean Philippe

“Ensuring the patient is safe by protecting them from any hazardous materials. Making sure all staff know who the patient is and what procedure we are doing. To prevent infection, I keep my instrument sterile and clean for the safety of the patient.”

-Michelle Palmer

What does patient safety mean to you?

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“Teamwork and communication starts in Preop and continues until the patient goes home. Important information is discussed about medication, allergies and post-operative care.”

-Darin Monte

“Everyone has to collaborate and work together to maintain the patient’s safe-ty.”

-Jamela Harris Clayton

“Clear communication between team members is crucial to ensure patient safety. Working as a team leads to safe patient outcomes and successful sur-geries.”

-Roland Williams

“Clear communication and teamwork are the basic ingredients to any suc-cessful outcome. By establishing a communication plan at the beginning of case and carrying it out as a team, it avoids errors, delays, and unnecessary time under anesthesia. This leads to faster recovery and healing time for the patient.”

-Angel Escobar-Reyes

“Teamwork is imperative. If everyone helps each other out, things will go smoothly. Clear Communication is important and can determine the pa-tient’s outcome.”

-Rafeeq Rainey

“There has to be clear communication about patient care. The goal is for the patient to have a safe and pleasant stay in their time of need.”

-Malcolm Waddell

“When several people work together as one they are making sure the patient is safe and eve-rything works accordingly.”

-Howard Davis

“Teamwork is probably the most important thing that goes on in the OR. Between Anesthe-sia, Surgeons, Techs, and Nurses, we all have to work together to ensure that patient is getting the best possible care.”

-Brittany Cannon

“When there is closed loop communication con-cerning patients, it leads to better outcomes. This keeps people on their toes, paying attention and remembering the patient is the entire focus in the room.”

-Lynne Satchell

“I think that is hands down the most important part of making sure that a patient is safe.”

-Amy Simpson

“Clear communication is very critical in our health system, especially when dealing with patients. Teamwork is vital in the OR because we cannot work without one another.”

-Grunderson Jean Philippe

How does teamwork and clear communication impact patient safety?

“Teamwork is when everyone in the room is involved: Anesthesia, Nursing, Surgical Techs and Service Partners. Clear multidisciplinary communication decreases the risk of unsafe conditions for the patient.”

-Michelle Palmer

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STOP and CORRECT unsafe behaviors or conditions. STOP and REPORT equipment abnormalities by

ENSURING equipment is in a safe condition pr ior to starting work.

NEVER proceed when faced with uncer tainty. Always STOP and SEEK guidance or assistance from a manager or content expert.

REMEMBER asking for help is a strength, not a weakness.

VALUE and EMBRACE feedback from your manager and peers.

KNOW your per sonal limits both physically and mentally.

DO NOT bypass required safeguards. REPORT all events.

VALUE staff feedback with thoughtful consideration. WELCOME and EMBRACE staff concerns in a non-

punitive manner. REMEMBER asking for help is a strength, not a weakness. KNOW your personal limits both physically and

mentally. PROVIDE follow-up when applicable to ENCOURAGE

continuous reporting. REPORT all events.

Purpose

Your life and the lives of your coworkers and

patients depend on making safe decisions on the job. The follow-ing fundamental guidelines have been established for your safety

while you work, and for the safety of others around you.

Habitual safe practices are your best insurance against patient

and staff injury.

Scope

Employees are responsible for maintaining a genuine safety

culture in compliance with rules and regulations and for

continuously practicing safety while performing their duties. Managers and Supervisors are responsible for developing and maintaining the proper attitudes toward perioperative safety and health in themselves and those they supervise. They are also

accountable for ensuring that all operations are performed with the utmost regard for the safety and health of the personnel or

patient involved, including themselves.

Implementation

Excellence in care is more likely

when people embrace the following core principles as the basis for desirable behaviors to

prevent errors before they occur.

Fundamental Behaviors Important to Staff and Patient

Safety for Employees

Fundamental Behaviors Important to Staff and Patient

Safety for Managers