Date of Graduation

Spring 5-17-2018

Document Access

Project/Capstone - Global access

Degree Name

Master of Science in Nursing (MSN)


School of Nursing and Health Professions

First Advisor

Francine Serafin-Dickson


Lack of standardization in the perioperative area leads to variations in practice that can cause preventable errors. In a 200-bed hospital in Northern California with eleven operating rooms preforming approximately 11,000 procedures a year, there was an increase incidence in sentinel events such as wrong site surgery (n=1), wrong patient surgery (n=1), and retained foreign body (n=5). Safety checks observed in the operating room (OR) were preformed differently among each surgical team and sometimes did not occur at all. Through the use of a Surgical Safety Checklist (SSC), efforts were aimed to standardize safety practices in the OR. The goal was to ensure 90% adherence to the requirements on the SSC based on observational assessment of the process within four months of implementation. Weekly observational audits were conducted over a four-month period to examine the adherence to each checklist component. The mean overall compliance increased in all three phases: Sign In (63% to 70%), Time Out (60% to 73%,) and Sign Out (85% to 100%). Seventeen good catches were identified in Patient Safety Reports that were identified in the following phases: Sign In (n=2), Time Out (n=9), and Sign Out (n=6) phase. The use of the Surgical Safety Checklist encouraged a standardized approach to enhance multidisciplinary teamwork and communication by ensuring the completion of critical tasks which lead to early recognition of “near misses”.

Included in

Surgery Commons