Team-Tested Practices

Eliminate Errors With Pre-Op Doubling Up

Nurses review procedure before patients go to OR

Tensions were high at the Ambulatory Surgery Center in Colorado.

Not all patients were getting the medications they needed before going into surgery, and the team was fragmented when the UBT decided to tackle an ongoing problem around missed orders.

In some cases, surgeons would see a patient after the nurse had gone through the preoperative process. Physicians would put in orders for antibiotics or anti-nausea medication up until a minute or two before surgery. By this point, the nurse already had handed off the patient and didn’t always catch the order.

The team proposed adding a second nurse to the procedure. 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.

The new system caught both missed antibiotics and other medication orders as well. Nurses jointly carried out all steps in a preoperative handoff, including getting a patient’s signature for the operation, confirming a patient’s identity and the procedure being performed.


Team co-leads Parker and Dixon

Co-leads Reina Parker, ward clerk, SEIU Local 105, and perianestheia manager Sara Dixon, RN.

“Patients have a sense of ‘wow, these people are really careful,’” says perianesthesia manager Sara Dixon, RN.

Team members felt the extra time paid off in fewer errors. 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.

“It’s important to make sure everyone puts in their two cents before you go forward with a plan of action,” physician co-lead and medical director Michael McNevin, MD says.

For more about this team's work to share with your team and spark performance improvement ideas, download a poster or PowerPoint.

21 people found this helpful. Was it helpful to you? YesNo