Eliminating perioperative adverse events at Ascension Health

For Ascension Health's Healthcare That Is Safe strategy, Sacred Heart Hospital (SHH) and Columbia St. Mary's (CSM) served as alpha sites to develop strategies to eliminate perioperative adverse events (POAEs). The alpha sites set an interim goal of a 50% reduction of POAEs, then 100%, or e...

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Bibliographic Details
Published in:	Joint Commission journal on quality and patient safety Vol. 33; no. 5; p. 256
Main Authors:	Ewing, Hella, Bruder, Greg, Baroco, Paul, Hill, Maria, Sparkman, Lora P
Format:	Journal Article
Language:	English
Published:	Netherlands 01-05-2007
Subjects:	Blood Loss, Surgical - prevention & control Catholicism Florida Hospitals, Religious - standards Humans Iatrogenic Disease - prevention & control Intraoperative Complications - prevention & control Medical Errors - prevention & control Multi-Institutional Systems - standards Myocardial Infarction - prevention & control Outcome and Process Assessment (Health Care) Perioperative Care - methods Perioperative Care - standards Risk Assessment Safety Management - methods Surgical Wound Infection - prevention & control Thromboembolism - prevention & control Venous Thrombosis - prevention & control Wisconsin Florida Wisconsin
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Summary:	For Ascension Health's Healthcare That Is Safe strategy, Sacred Heart Hospital (SHH) and Columbia St. Mary's (CSM) served as alpha sites to develop strategies to eliminate perioperative adverse events (POAEs). The alpha sites set an interim goal of a 50% reduction of POAEs, then 100%, or elimination of POAEs by July 2008. The alpha sites identified a process for data management to establish clear, measurable elements for each of the five strategies of the alpha initiative; created an infrastructure to foster transformational change in the operating room suite; and implemented tactics to measure the success of the five strategies. STRATEGIES AND TACTICS: The sites implemented tactics for five strategies: (1) prevention of errors due to human factors, (2) prevention of surgical site infections, (3) prevention of adverse perioperative cardiac events, (4) prevention of postoperative venous thromboembolism, and (5) prevention of postoperative hemorrhage. Both alpha sites achieved > or = 90% reduction in the POAE rate. A number of key learnings were drawn from the alpha experiences, including the need to adjust to evolving definitions and guidelines for implementation and measurement of perioperative care.
ISSN:	1553-7250
DOI:	10.1016/S1553-7250(07)33030-4