Eliminating perioperative adverse events at Ascension Health.
BACKGROUND
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.


METHODS
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.


RESULTS
Both alpha sites achieved > or = 90% reduction in the POAE rate.


CONCLUSIONS
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.
Ewing
Hella
H
Sacred Heart Health System, Pensacola, Florida, USA. hewing@shhpens.org
Bruder
Greg
G
Baroco
Paul
P
Hill
Maria
M
Sparkman
Lora P
LP
D016063:Blood Loss, Surgical / Q000517:prevention & control; D002410:Catholicism; D005431:Florida; D016519:Hospitals, Religious / Q000592:standards*; D006801:Humans; D007049:Iatrogenic Disease / Q000517:prevention & control*; D007431:Intraoperative Complications / Q000517:prevention & control*; D019300:Medical Errors / Q000517:prevention & control*; D009096:Multi-Institutional Systems / Q000592:standards; D009203:Myocardial Infarction / Q000517:prevention & control; D010043:Outcome and Process Assessment, Health Care; D019990:Perioperative Care / Q000379:methods / Q000592:standards*; D018570:Risk Assessment; D017751:Safety Management / Q000379:methods*; D013530:Surgical Wound Infection / Q000517:prevention & control; D013923:Thromboembolism / Q000517:prevention & control; D020246:Venous Thrombosis / Q000517:prevention & control; D014922:Wisconsin