Culture of Safety - Crozer-Keystone Health System - PA

Culture of Safety

Crozer-Keystone Health System nurses participate in numerous initiatives to promote patient safety. View the information below to read about a few of those initiatives.

Universal Protocol: Protecting Patients from Wrong-Site Surgery

Nancy Politharos, RN, MSN, and

Diane Beatty, RN, MSN, OCN.

CKHS has participated in the VHA’s Transformation of the Operating Room (TOR) initiative to improve patient safety since 2006. Related to this effort is the development of a universal protocol to protect patients from wrong-site surgery, one of the Joint Commission’s National Patient Safety Goals. Preventing wrong site surgery was also identified this year as a top priority of the Partnership for Patient Care collaborative, which includes the Delaware Valley Healthcare Council. 

In 2007, a nursing-driven multidisciplinary team led by Nancy Politharos, RN, MSN, assistant vice president for Patient Services at Taylor Hospital, was formed to develop system-wide policies and procedures for universal protocol. The protocol includes a pre-operative verification process, site marking and a final time out before the start of the procedure.

After conducting a self-assessment survey to identify causes of wrong-site surgery and process vulnerabilities at CKHS hospitals, the team determined that the critically important final time-out process needed to be redesigned to ensure that all members of the surgical team present in the OR at the time of surgery were actively engaged and interacting in the process. The circulating nurse plays a pivotal role by asking scripted questions that require more than a yes/no answer from the surgeon, anesthesiologist and other team members to ensure accuracy.

The protocol team completed the redesign and created a new observational checklist tool to audit compliance with the new time out procedure, setting a goal of a 10 percent improvement by the end of calendar year 2008. Progress is monitored by random surgical chart reviews and/or random audits completed monthly by OR nurse managers at each hospital. To help ensure success, nursing leadership provided education to the physicians about the importance of active engagement in the timeout, as well as conducting in-services for the nursing staff.

CKHS hospitals also implemented a new written and verbal verification procedure for taking surgical reservations. The surgeon is asked to call in the reservation, followed by a written fax confirmation, which the nurse reconfirms with a second phone call to the physician. Ensuring that the correct information is taken at the time of reservation is expected to reduce the risk of wrong site surgery. CKHS has set a goal of 90 percent compliance with this verification procedure by the end of December 2008.

The universal protocol team also developed a process for identifying and reviewing near misses in the OR with. This process will be used to educate the staff about the factors involved in near misses so they can be avoided in the future. 

In addition to the OR, the universal protocol is now used in other areas of CKHS hospitals where procedures are done, such as the bedside, Cardiac Catheterization Laboratory, Gastroenterology Laboratory and Interventional Radiology. 

Rapid Response Teams Reduce Codes

Angel McCullough, RN, MBA, CNA-BC

In 2006, Crozer-Keystone hospitals implemented Rapid Response Teams (RRT) in response to the Institute for Healthcare Improvement’s 100,000 Lives Campaign. Also tied to the Joint Commission National Patient Safety Goals, the RRT aims to reduce the number of situations outside critical care units where patients code or need resuscitation. Crozer-Keystone has achieved this by empowering the nursing staff to directly request assistance from a team of clinicians who bring critical care expertise to the bedside when a patient’s condition appears to be worsening.  The RRT at each CKHS hospital includes a critical care nurse, respiratory therapist and a hospitalist.

Education was vital to the success of the RRTs. During in-service training, nurses were encouraged to trust their gut instincts. “When in doubt about whether a patient’s condition is deteriorating, nurses should call the RRT,” says Angel McCullough, RN, MBA, NE-BC, head of Crozer-Chester Medical Center’s Resuscitation Committee. “It is much better to err on the side of patient safety and catch them before they decompensate to the point of coding.”

Lisa Eckenrode, RN, BS, MBA

“The nursing staff fully embraced the idea of RRT, especially when they understood that their gut instincts were considered valid concerns,” says Lisa Eckenrode, RN, BS, MBA, clinical nurse educator in Taylor’s Emergency Department. She also notes that Taylor’s policy is to call the RRT for any individual in the hospital who needs attention, including outpatients and visitors. Training at Taylor has included non-clinical staff such as volunteers and business office staff.

RRT education with Crozer-Keystone hospitals has focused on recognizing the signs and symptoms of stroke and sepsis. CKHS hospitals are currently working on a sepsis bundle so nurses can more effectively intervene before septic shock occurs.

RRT success has been measured by patient outcomes, including the number stabilized on the unit, the number who required a higher level of care and the number of Code 99s called. Since implementing the RRTs, the number of patients stabilized on the unit has trended upward, and a positive correlation has been seen with patient recovery and earlier discharge.

CKHS Rapid Response Team - Patient Outcomes

Averages: January - June 2008



On Unit

Transferred to

Higher Care Level

























“A Culture of Safety” Video Produced to Educate Employees

As part of the health system’s continued commitment to increasing patient safety and avoiding medical errors, Crozer-Keystone produced a seven-minute video entitled “A Culture of Safety.”

The video features Crozer-Keystone employees, including several nurses, talking about real situations in which patient safety errors were made at CKHS hospitals. The goal of the project is to help employees learn more about how common errors may occur and tips for preventing them. 

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