Early in 2024, the Post-Anesthesia Care Unit (PACU) identified nine surgical site infections (SSIs) among orthopedic surgery patients. Committed to their goal of zero harm, the team launched a quality improvement initiative using the Plan-Do-Study-Act methodology to reduce SSIs in this population.

As part of the intervention, the PACU team revised discharge instructions and trained nurses to use a standardized script that included three teach-back questions to confirm patient understanding of post-operative care.

Following the implementation of this standardized discharge teach-back process, the PACU achieved zero SSIs for three consecutive months. Proud of this success, the team submitted their project to the Research & Innovation Academy (RIA) conference and were selected as podium presenters. Vernon Newton, BSN, PHN, RN, and Mallory Stevens, BSN, RN, represented San Leandro’s PACU team at the 2025 RIA conference to share their achievement in advancing the goal of zero harm.