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Regional Safety Plan Reset Decreases Patient Harm Events by 25%
Danyal Ibrahim2, Philip Corvo1, Colin McGuirk2, Benjamin Dahlberg1
1Surgery, St Mary's, Fairfield, Connecticut, United States, 2Trinity Health Of New England, Hartford, Connecticut, United States

Objective(s):
To decrease the incident number of wrong site, wrong surgery and retained foreign objects

Design:
Before and after comparison of groups after interventions

Setting:
Regional Healthcare System

Patients:
18,000 surgical patients pre-intervention vs 19,000 surgical patients post intervention

Interventions:
1) Create a sense of urgency to drive change to prevent harm
2) Build and strengthen the foundation for eliminating harm by ensuring that leaders actively promote a culture of safety
3) Identify High Risk areas and procedures
4) Reinstitute Gemba walks, leadership rounds and accountability huddles
5) Renewed focus on pre-operative time-outs, post-operative debriefs and created new sponge accounting techniques
6) Re-educate, not reprimand, for misses and near misses
7) Celebrate Great Catches
8) Review events and issues daily with teams

Main Outcome Measure(s):
Pre and post intervention incidents of: 1) Wrong Site Surgery, 2) Wrong Surgery 3) Retained Sponges and foreign objects

Results:
1) A 25% reduction in overall harm by eliminating 12 avoidable events in total (45 to 33 Serious Reportable Events)
2) A 50% reduction in Wrong Site Surgery
3) A 100% reduction in Wrong Surgery / procedure
4) A 33% reduction in retained foreign bodies.

Conclusions:
Creating a sense of urgency to focus teams on proven aspects of a culture of safety resulted in an overal 25% reduction in harm is a regional health system.


50% Reduction of Harm in Procedural Areas
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