AB130. SOH25_AB_100. Safe site surgery bi-annual audit—University of Limerick Hospitals Group
Anaesthesia Session

AB130. SOH25_AB_100. Safe site surgery bi-annual audit—University of Limerick Hospitals Group

Mary Joyce1, Beth Farren2, Gavin O’Connor1, Muhammad Safullah1

1Department of Anaesthesia, University Hospital Limerick, Limerick, Ireland; 2Peri-Operative Directorate Management Team, University Hospital Limerick, Limerick, Ireland

Background: The Health Service Executive (HSE) National Policy and Procedure for Safe Surgery [2022] was implemented across the University of Limerick Hospitals Group to enhance patient safety during surgeries. This audit, the first since policy implementation, aims to assess compliance with the policy’s safety standards, targeting an initial compliance rate of 85% across the hospitals.

Methods: The audit comprised both retrospective and concurrent observational methods. A total of 50 cases were reviewed: 28 cases were retrospective chart audits, and 22 cases involved real-time observations. The selected cases excluded the maternity hospital. Data was gathered using the HSE national audit tool, which evaluates both structure and process adherence to safe surgery standards.

Results: The overall compliance rate was 95%, surpassing the initial target of 85%. While most areas showed high compliance, some weaknesses were identified, such as only 4% compliance with recording the procedure date. Other key results highlighted full compliance with surgical site marking and patient identity confirmation, but documentation of consent by attending clinicians and debriefing attendance showed room for improvement.

Conclusions: The audit demonstrated successful adherence to the safe surgery policy, with a focus on improving compliance for 100% in future audits. Areas needing attention include better engagement in team debriefings and enhancing documentation practices. Recommendations include improved communication of audit results and continuous bi-annual audits, with the next scheduled for February 2025.

Keywords: Compliance; debriefing; documentation; safety; surgery

Acknowledgments

None.

Footnote

Funding: None.

Conflicts of Interest: The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

doi: 10.21037/map-25-ab130
Cite this abstract as: Joyce M, Farren B, O’Connor G, Safullah M. AB130. SOH25_AB_100. Safe site surgery bi-annual audit—University of Limerick Hospitals Group. Mesentery Peritoneum 2025;9:AB130.

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