Targeting Pre-Operative Booking Processes to Decrease Risks of Never Events

Abstract Problem: Wrong patient, wrong procedure, wrong site, and wrong side surgeries are such egregious errors that are known as “never events.” Root cause analyses can pinpoint a failure yet do little to determine if corrective action has reduced the risk of recurrence. Context: Monitoring surgical cases prospectively to identify weaknesses that could help identify specific risk factors to avert and move toward zero defects. The setting for this quality improvement project is a \u3e300-bed Level III trauma hospital, where the risk of wrong-site surgeries and lack of standardized processes in the surgical pre-operative booking process was of concern to organizational leadership. Interventions: The project used The Joint Commission Center for Transforming Healthcare Safe Surgery Targeted Solutions Tool® (SS TST®) to identify, measure, and correct preoperative booking defects. Additionally, a pre/post-intervention questionnaire was used to measure surgical schedulers’ process satisfaction. Measures: The outcome measures were changes in the number and types of pre-booking defects. Evaluation of surgical scheduler staff satisfaction began with existing workflow practices and concluded with workflow change evaluation. Results: This project facilitated change in standardizing the perioperative process to decrease risk by 47%, a relative improvement of 53.4%, recognized scheduler concerns, and implemented mitigating strategies. Conclusions: Using the SS TST®, the hospital and the participating physician offices recognized the risk associated with booking surgical procedures via phone versus written submission. Standardizing online surgical booking improved surgical scheduler satisfaction. Dissemination: The data was disseminated to the host facility, pilot test sites, and corporate leadership