75 - Our Surgical Safety Journey at Phoenix Children's

Description: At Phoenix Children's, we recognized a critical need to enhance surgical safety practices within perioperative services. Despite long-standing national efforts to improve surgical outcomes, our internal review revealed inconsistent adherence to critical protocols like the Universal Protocol and Surgical Safety Checklist. Over an 18-month period, these inconsistencies contributed to 11 safety events or near misses, signaling gaps in both compliance and culture. To address these issues, we launched a multidisciplinary initiative focused on evaluating and transforming our surgical safety practices. We formed an overarching Surgical Safety committee with physician champions, frontline staff, perioperative leadership, including our quality and risk management partners. Within the Surgical Safety committee, we defined six subcommittees established to refine or redesign critical workflows. Our assessment revealed several core challenges that were impacting surgical safety. There was inconsistent compliance with evidence-based safety tools, which undermined standardized best practices. Time constraints led to critical safety steps being omitted. Hierarchical dynamics and poor communication. Variability in surgical counts and system-wide inconsistent safety practices. To strengthen surgical safety practices, several standardized processes were implemented across the perioperative workflow. We trained over 500 staff members, integrated the revised processes into every surgical division, and launched a Command Center for real-time support during go-live. Resources included safety coaches, digital toolkits, QR codes for on-the-spot feedback, and the appointment of Safe Surgery Champions to promote sustainability.
Our transformation journey is vital because it illustrates how a culture of safety isn't achieved through policy alone — it requires deliberate, collective action. By embedding standardized safety practices across the surgical continuum and empowering every team member to participate in a shared commitment to excellence, we are moving toward a high-reliability surgical environment

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