Date of Graduation

Fall 12-17-2021

Document Access

Restricted Project/Capstone - USF access only

Degree Name

Master of Science in Nursing (MSN)


School of Nursing and Health Professions


Kaiser cohort MSN capstone

First Advisor

Carla S. Martin, MSN, RN, CIC, CNL, NEA-BC


Problem: Surgical site infections can be prevented by improving adherence to evidence-based infection control practices of surgical instrumentation sterilization protocols. With education and departmental cultural changes, operating room scrub personnel learn the importance of point-of-use pre-cleaning of surgical instruments and increase adherence to protocol. Context: A ten operating room intra-operative department in a non-trauma hospital of a large health care system created a quality improvement project to decrease surgical site infection rates by increasing scrub personnel adherence to pre-cleaning protocol and safely transporting surgical instruments to the Central Sterile Processing (CSP) department. Interventions: A formal education session and huddle messages for five weekdays were provided to operating room nurses and surgical technicians. Measures: The adherence to protocol was measured through audits on the condition of the surgical instruments transported to CSP before and after the education and huddle sessions. Results: Surgical scrub personnel adherence to surgical instrument pre-cleaning protocol increased from 5% to 50% after formal education and staff huddles. Staff self-assessment of protocol adherence was 91% ten weeks after formal education. Conclusion: Formal education and enhanced staff awareness are effective strategies to increase staff adherence to evidence-based practice protocol. Future analysis of SSI rate after this project is necessary to measure SSI improvements and to plan further strategies for staff protocol adherence sustainment.

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