Errors drop with pre-op doubling up

Department: Ambulatory Surgery Center, Colorado

Value Compass: Quality

Problem: Patients were not getting antibiotics before going into surgery.

Metric: Number of patients who did not receive their ordered antibiotics.

Labor co-lead: Sue Rura, RN, UFCW Local 7

Management co-lead: Sara Dixon, RN, perianesthesia manager

Physician co-lead: Michael McNevin, MD, medical director

Small test of change: Before a patient is sent to the operating room, the pre-operative nurse and the OR nurse together review a checklist that includes last-minute orders from physicians. Previously, only one nurse reviewed the list.

Result: In less than two months of implementing the new system, the team went from 10.8 percent of missed antibiotic orders to 0.27 percent—or two out of 735 patients.

“With all the checks we do now, we almost never miss any orders,” says manager Dixon.

Next step: Expanding the new system to all medication orders and Centers for Medicare and Medicaid requirements.

Advice to other UBT teams: “It’s important to make sure everyone puts in their two cents before you go forward with a plan of action,” says co-lead Dr. McNevin. “I’m a doc and I know everything,” he adds jokingly. “Then someone tells me their opinion and I say, ‘Hmm, I hadn’t thought of it that way!’ ”