Date of Graduation

Summer 8-2015

Document Access

Project/Capstone - Global access

Degree Name

Master of Science in Nursing (MSN)


School of Nursing and Health Professions


The ending data reflected what we expected in that we would see a significant incline but

not quite the 100% compliance rate we are looking for. Our highest compliance rate has reached

90% and we have contributed the margin error to new staff that requires the proper teaching and

education. In conclusion I feel that the majority of staff was aware that they were not in

compliance with the time out but would proceed anyways due to the rush of the case or surgeon

or simply that they had become laxed in practice. Once the data was brought to staff attention

and the tracer audits began we saw a quick rise to expectations. Majority of tracer audits were

not announced which forced staff to comply with each case.

Repetition is seen as a way to increase improvement, my plan for sustainability will have

much to do with repetition. The surgical time out is a procedure that is performed with every

surgical case so the opportunity to practice / repeat is possible more than one time a day. As staff

members in the OR repeat the updated time out the correct way it will reinforce the policy and

assist in making it habit. During the Do phase of the SDSA cycle we will be giving and obtaining

feedback on what is working well and what is not, any barriers, as well as positive

reinforcement. We have discovered that speaking with individuals one on one privately is

effective because it holds that individual accountable regarding their faulty performance, but also

excludes the embarrassment or anger that would come in a group situation. Positive

reinforcement and recognition in the morning huddle however is a nice way to start the day,

individuals enjoy being recognized for a job well done.

Tracer audits will continue to be performed on a weekly or bi weekly basis and also as

surprise audits to assure we are keeping on track. There will continue to be new barriers,

suggestions, concerns, etc. that will arise and the only way to continue to improve is to keep a

record, the statistical analysis and numbers will show our progress and sustainability or lack of.

The work that is being put into this project has become standard, the nurse educator and unit

manager have agreed that tracer audits will continue on a regular basis, nurses who find

themselves with down time will perform audits on the surgical time out and data will be reported

for analysis. The sustainability concept falls in line with the values / mission statement of the

hospital to "enhance the well-being of people in the communities we serve through a not-for-

profit commitment to compassion and excellence in health care services."