198 - From Silence to Safety: The Power of Voice in Preventing Surgical Injuries

Description: From Silence to Safety: The Power of Communication in Preventing Surgical Injuries

Situation: Following an intensive training session dedicated to preventing pressure injuries, which included immersive and realistic simulations, the team came to a profound realization. They had previously underestimated the significant risks associated with the intraoperative period, which had led to a concerning rise in reported injuries within the hospital. This newfound awareness prompted the establishment of a comprehensive communication framework designed to bridge the gap between operating room nurses and inpatient units. The aim was to enhance the detection of pressure injury incidents, thereby fostering a culture of vigilance and accountability. This improvement project focused on developing a robust communication strategy that would not only strengthen the tracking of injuries but also facilitate the identification and correlation of these injuries to patient positioning, ultimately supporting proactive preventive measures.

Assessment: A specialized communication channel was created to evaluate pressure injury risk through the ELPO Scale. Patients identified as high-risk (with an ELPO score greater than 20) intraoperatively are carefully monitored until the third postoperative day. This vigilant oversight allows for the timely identification and implementation of tailored preventive strategies, ensuring the utmost care for patients during their recovery.

Results: The nursing team diligently compiles and disseminates a daily list of high-risk patients to the Hospital Healing Committee, which plays a pivotal role in informing the inpatient nursing coordinators. Following patient discharge, the inpatient units carry out thorough assessments for pressure injuries. In situations where injuries are identified and linked to surgical procedures, these cases are reported to foster the advancement of preventive measures and to mitigate the occurrence of similar incidents in the future.

Implications for Practice: Injuries that were once overlooked due to the complexities of surgical positioning are now meticulously monitored. This active oversight enables healthcare providers to implement targeted preventive strategies for patients, thereby significantly reducing the likelihood of recurrence. This study highlights the critical role of effective communication in preventing surgical injuries and emphasizes the importance of involving all professionals involved in the patient's surgical experience. By fostering collaborative partnerships between perioperative nurses and clinical nurses, the tracking of incidents can be improved. This support facilitates the implementation of preventive measures, ultimately contributing to a safer and more patient-centered surgical environment.