Date of Graduation

Winter 12-17-2021

Document Type


Degree Name

Doctor of Nursing Practice (DNP)


School of Nursing and Health Professions




Executive Leader DNP

First Advisor

Dr. Juli Maxworthy

Second Advisor

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.

Included in

Nursing Commons