The journey to zero harm in the OR: Insights and best practices from Cleveland Clinic

High-reliability health systems operate under the premise that humans are fallible and errors are unavoidable, even in the best organizations. To support the journey to zero harm, healthcare leaders create systematic solutions by using safety processes and integrative technologies in tandem.

Becker’s Hospital Review recently spoke with Dena Salamon, MSN, RN, director of main OR at Cleveland Clinic, about the organization’s safety priorities and how operating room teams achieve safety goals.

A culture of safety promotes employee feedback, communication and continuous improvement

Cleveland Clinic has a department dedicated exclusively to quality and safety, which focuses on the continuous enhancement of safety for all patients, employees and visitors. This well-rounded program forms the foundation of the organization’s safety culture.

According to Ms. Salamon, “We are committed to a just culture so we can improve the care we deliver and prevent potential errors. It’s not meant to be punitive. Employees are encouraged to speak up when they see something isn’t right. That gives the quality and safety department a chance to improve processes and change workflows so we can practice in the safest manner. One of our top priorities is meeting the national patient safety goals set by The Joint Commission.”

Communication plays a central role in Cleveland Clinic’s commitment to safety. In fact, Ms. Salamon noted, “If communication is lacking in a healthcare organization, it can really make or break you in terms of safety.” Before and during every surgical case, the interdisciplinary team and patient communicate with one another. The surgeon, anesthesia, the circulating nurse, the patient and anyone involved in the patient’s care participates in a meeting called a huddle.

“We want patients to speak up and take part in their care,” Ms. Salamon said. “We think that’s very important. It helps us to hit the necessary things during the surgical procedure.”

Robust education in the perioperative space may reduce the risk of harm for patients and providers

Cleveland Clinic has developed a thorough education program for nurses, surgical techs and surgical assistants. This includes weekly in-services to ensure everyone is trained and knows how to do the right thing. “We continually introduce new products into the OR,” Ms. Salamon said. “We want everyone to feel comfortable with them and to understand their usage. The in-services provide them with the opportunity to ask questions and to do a deep dive.”

In addition, surgeons routinely conduct morbidity and mortality conferences. Nurses are welcome to join if there is a particular case they are interested in or if they were part of something where they would like more education.

Cleveland Clinic has approximately 54 operating rooms in the main OR. This excludes cardiac, vascular and thoracic. Nurses that have been newly hired for the OR must participate in a six-month orientation. They are educated within the subspecialty that they were hired into. At the end of their orientation, new hire nurses may visit other services to familiarize themselves with product locations and people who can answer questions.

Given the importance of OR safety, Cleveland Clinic is also reaching back into the talent pipeline and participating in outreach with nursing schools to make sure that perioperative nursing practices — including safety — are incorporated into their curricula.

Well-defined processes may minimize the impact of common hazards in the OR

To reduce or eliminate the risks associated with common operating room hazards, Cleveland Clinic has adopted a variety of protocols. Surgical teams use timeouts, for example, to minimize distractions. “Before a surgical incision is made, every participating team member in the operating room stops for a timeout,” Ms. Salamon said. “Even if you are simply in the room to retrieve a supply, you must pause if a timeout begins.”

Another important OR process is the safety checklist. Cleveland Clinic has integrated safety checklists into the preop, postop and intra-op phases of surgical procedures. “The safety checklist is similar to what a pilot does before taking off in a plane,” Ms. Salamon said. “We make sure we have all the medications and equipment we need. We confirm that we have the correct patient and are prepared to do the right procedure. These are all areas that we cover before making a skin incision.”

When the procedure is over, the surgeons conduct a sign-out process, recapping what they did, outlining the postop care plan and enumerating the specimens that were removed and where they need to go. All of this helps deliver the best results possible for patients.

In addition to timeouts, safety checklists and sign-outs, Cleveland Clinic’s OR teams have guidelines for routine surgical items that are burn risks like electronic scalpels. These pieces of equipment are stored in a safe, secure place to prevent burns on patients, team members and even surgical drapes.

A variety of technologies help healthcare organizations achieve OR safety goals

Technology plays an important part in Cleveland Clinic’s OR safety efforts. The organization uses a safety event reporting system team members refer to as SERS. “SERS gives employees the opportunity to report near misses, process problems or patient events,” Ms. Salamon said. “All that information goes to our quality department where they run reports and determine whether we need to investigate further with an interdisciplinary team.”

Within the walls of the operating room, surgical teams use an EMR module called OpTime which makes charting seamless. It’s easy for OR nurses to look up information and add documentation, such as counting data, specimen information or even personnel changes.

In the OR setting, Cleveland Clinic has added an adjunct technology to enable nursing teams and surgical techs to scan sponges at the beginning of a procedure, as well as at the end, before the surgeon closes the patient. This serves as a failsafe that no sponges have been left behind.

“This has really made a difference in the nurses’ workflow,” Ms. Salamon said. “Hunting for a missing sponge can take a significant amount of time. This technology has been a huge asset for us and we’ve used it for many years.”

Health systems don’t need to “go it alone” on their journey to zero harm

For two decades, Stryker has been investing in caregiver safety. The company’s innovative and standardized solutions for the OR, as well as its education and implementation resources, have been designed to help healthcare organizations achieve safety goals.

As Ms. Salamon noted, retained surgical items like sponges are a safety concern that has endured for years. The Joint Commission launched Sentinel Event reporting in 1996, and every year, retained surgical items have been on the list of top events that cause death, permanent harm or severe temporary harm. Stryker’s SurgiCount+ is an adjunct technology with a track record of zero retained surgical sponges, when implemented and used correctly. To simplify clinician workflows, SurgiCount+ supports full EMR connectivity and back-end compliance.

From an environmental perspective, caregivers and patients in the operating room may also be exposed to dangerous splashes and spills, bacterial and viral particulates and airborne chemicals and pollutants. According to OSHA research, suction canisters yield a 60 percent splash incidence rate. Stryker’s Neptune is unique, as the only constantly closed waste management solution on the market. It also comes standard with integrated HEPA and ULPA filters to protect the air that clinicians and patients breathe in the OR.

Surgical smoke has been found to contain over 150 chemicals and 16 EPA priority pollutants. Stryker’s Neptune system and the SafeAir Compact both offer ULPA filtration for standardizing open smoke evaluation. These solutions can be paired with any of Stryker’s ergonomic smoke evaluation solutions.

Even something as simple as the flooring in the OR can contribute to safety concerns. Studies have found slips, trips and falls account for 20 percent of healthcare worker lost time injuries. Given the talent shortages in healthcare today, hospitals and health systems can’t afford to have clinicians out due to injuries. One solution is Stryker’s disposable QuickWick mats which plug into the Neptune Waste Management system to keep the floor of the OR and procedural spaces dry.


There is no silver bullet for achieving zero harm in the operating room. Instead, health systems must leverage a portfolio of tools and techniques. “When everyone is educated, feels supported and knows what they need to do, that’s huge,” Ms. Salamon said. “Our end goal is to ensure all patients get the surgical care that they need and that both patients and caregivers are safe.”

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