Safety/Quality

Patient Safety Fellows

Nurses at UCSF Medical Center care deeply about patient safety as they care for patients on a 24/7 basis, and play a unique role in communicating and advocating for safe patient care. In such a complex healthcare setting as here at UCSF Medical Center, the needs are numerous, dynamic and ongoing.

The Patient Safety Fellows was formed to address such patient safety needs and is a nurse-driven hospital committee whose mission is to support nurses’ critical role as caregivers by giving them a voice, the means, and resources to effect meaningful change on a personal, unit-based, and hospital-wide level. The group meets monthly to identify, discuss, and offer solutions to the safety concerns raised by direct care nurses. Patient safety issues and potential solutions are channeled to the appropriate hospital administrator for resolution.

As part of the goal to educate nurses about their vital role in supporting patient safety, the committee offers two classes which provide valuable forums to share and learn from actual patient experiences. The first class, titled “Stories from the Bedside”, presents oral narratives so nurses can learn collectively from each other’s experiences, share lessons learned, and improve practice. In addition, nurses, patients and their family members have presented stories about their hospital experiences. Among the topics covered have been “Transferring Patients to ICU” which has resulted in major policy changes including safe transport of unstable patients. The second class teaches a communication skills class where real life scenarios are used to support nurses’ clinical development of critical thinking and effective communication.

The Patient Safety Fellows foster a culture of patient safety, engaging patients and staff, while supporting patients on their journey through the healthcare system. Patient safety remains the heart and soul of the work nurses do everyday, and thanks to the Patient Safety Fellows, these efforts are continually being improved and advanced.

Sponge Count Technology Improves Patient Safety

Despite national standards for sponge-counting, this common operating room (OR) task is error prone for multiple reasons. In 2006, the Perioperative management and operating room nurses began their journey to identify suitable solutions to assist nurses with sponge counting.

The goal has always been to improve patient safety and OR efficiency.  Unintentional retention of a foreign body after surgery, such as a sponge, is a preventable error.  Adverse patient outcomes include sepsis, infection, second surgery to remove the object, and prolonged length of stay.  Failure to maintain an accurate sponge count resulting in retained sponges is a medical error that can cause patient harm, adverse publicity and increased licensing body investigations and penalties.

Since 2007, Perioperative Services has implemented the data matrix code system SurgiCount Safety - Sponge System in an effort to address this risk and improve patient safety. Similar to barcoding technology used for the retail industry, each sponge in the Safety - Sponge System is embedded with a unique identification number, so the system can identify if a sponge is missing.

Implementation of this new code system did entail training and workflow changes not only from a technological perspective, but also related to changes in equipment needs, communication, and efficiency which positively impacted teamwork amongst the perioperative staff.

Prior to implementation, the incidence of having a retained sponge occurred approximately once every three months. Following implementation of the SurgiCount Safety - Sponge System, no retained sponge cases have been noted for three years. Use of the system did not prolong OR case duration or have a negative impact on workflow, and the system proved to be highly reliable. Adherence to practices related to counting, documentation and communication leads to improved outcomes for patients. Implementation of SurgiCount Safety - Sponge System has helped UCSF improve patient safety by providing the technology to support a standard, efficient and easy-to-use process to complete sponge counts in the OR.