Northbank Surgical Center, in Salem, OR, recently was recognized for safety efforts that included investigating an instrument through the Food and Drug Administration (FDA) MedWatch program and sharing its findings with other facilities. The center also was recognized for implementing a safety checklist and launching a patient satisfaction program.
The Center was recognized as an exemplary leader in Oregon’s Patient Safety Reporting Program. It received the top award, the Leading Participant Award, from the Oregon Patient Safety Commission, along with the Oregon Outpatient Surgery Center in Tigard. The award is for organizations that consistently investigate patient harms, develop solutions to prevent future harm, and submit reports that effectively contribute to shared learning.
The defective instrument was a tissue fusion system used for gynecological procedures that caused a patient burn, says Pat Clark, RN, who is the clinical quality control coordinator at Northbank. “We had done everything according to manufacturer recommendation,” Clark says.
The center sent a report to the Oregon Patient Safety Commission. The Commission informed the center that the FDA had sent a letter to the company, requested follow up, but the matter had not been resolved. “This led us to believe that there had been other burns from the same type of instrument used in the same way,” Clark says. The Center immediately stopped using the instrument.
The Center made a MedWatch report to the FDA (http://www.fda.gov/Safety/MedWatch). The Oregon Commission distributed the information in reports and newsletters. Also, because Northbank is part of Surgical Care Affiliates (SCA), that chain sent a mass email letting other centers know about the problem with the instrument.
The Center used a form to begin the root cause analysis (RCA). [See form enclosed in the online issue. For assistance, contact customer service at customerservice@ahcmedia or call (800) 688-2421.] The form is distributed to everyone involved in the incident, and they each write what their role was in the incident and what they observed. “We bring them together to brainstorm,” Clark says.
The center had a Rapid Response Root RCA call that involves the SCA regional vice president, the regional director of clinical services, the regional quality coordinator, the regional clinical champion, and from Northbank, the administrator, OR and PACU managers, teammates involved in the RCA, and Clark. These calls are held within 72 hours of an event, if possible.
The staff members begin at the start and look at the steps to determine what could be done to prevent adverse incidents. They dig deep to determine what can be changed or if anything was in place but not followed, Clark emphasizes. “We don’t stop with the first thing we come to,” she says. “We ask, ‘If we fixed that, what else?’”
The surgery center employees allow others to ask questions and help them to dig deeper if necessary,” Clark says. “We don’t stop until we have looked at all avenues, because one of our SCA values is clinical quality,” she says. The group reviews action items, and then a follow-up call is held in 90 days.
The center also was honored for its safety checklist, which was developed to make it easily accessible and user-friendly, “always there when nurses needed it without having multiple forms to look for,” Clark says. It’s part of the chart that follows the patient from preop throughout the surgical experience to recovery. (The checklist also is enclosed with the online issue.)
Also receiving awards in Oregon for exceeding the recognition targets were Corvallis Clinic Surgery Center, Corvallis; East Portland Surgery Center, Portland; and Slocum Surgery Center, Eugene. Receiving awards for meeting recognition targets were Northwest Ambulatory Surgery Center, Portland; Oregon Endoscopy Center, Eugene; Oregon Surgicenter, Eugene; and River Road Surgery Center, Salem.