Date of Graduation
Doctor of Nursing Practice (DNP)
School of Nursing and Health Professions
Executive Leader DNP
Dr. Juli Maxworthy
Dr. Elena Capella
Problem: Wrong patient, wrong procedure, wrong site, and wrong side surgeries are such egregious errors that are known as “never events.” Root cause analyses can pinpoint a failure yet do little to determine if corrective action has reduced the risk of recurrence.
Context: Monitoring surgical cases prospectively to identify weaknesses that could help identify specific risk factors to avert and move toward zero defects. The setting for this quality improvement project is a >300-bed Level III trauma hospital, where the risk of wrong-site surgeries and lack of standardized processes in the surgical pre-operative booking process was of concern to organizational leadership.
Interventions: The project used The Joint Commission Center for Transforming Healthcare Safe Surgery Targeted Solutions Tool® (SS TST®) to identify, measure, and correct preoperative booking defects. Additionally, a pre/post-intervention questionnaire was used to measure surgical schedulers’ process satisfaction.
Measures: The outcome measures were changes in the number and types of pre-booking defects. Evaluation of surgical scheduler staff satisfaction began with existing workflow practices and concluded with workflow change evaluation.
Results: This project facilitated change in standardizing the perioperative process to decrease risk by 47%, a relative improvement of 53.4%, recognized scheduler concerns, and implemented mitigating strategies.
Conclusions: Using the SS TST®, the hospital and the participating physician offices recognized the risk associated with booking surgical procedures via phone versus written submission. Standardizing online surgical booking improved surgical scheduler satisfaction.
Dissemination: The data was disseminated to the host facility, pilot test sites, and corporate leadership.
Poths, Rebecca Lynn and Poths, Rebecca Lynn, "Targeting Pre-Operative Booking Processes to Decrease Risks of "Never Events"" (2021). Doctor of Nursing Practice (DNP) Projects. 277.