Degree Name
Nursing Practice, DNP
Publication Date
2-16-2026
First Advisor
Sandra King
Second Advisor
Veronica Arredondo
Abstract
Surgical errors in ambulatory and in-office procedural settings continue to rise despite well-established safety standards, such as the time-out (TO) protocol. Literature consistently links non-adherence to the TO protocol to preventable events such as wrong patient, wrong site, or wrong surgery. At the cardiovascular ambulatory clinic where the quality improvement (QI) project was implemented, the baseline needs assessment indicated inconsistent TO practices and the absence of a standardized tool to support TO. The purpose of this project was to improve adherence to the TO safety protocol through staff education and implementation of the evidence-based World Health Organization (WHO) Surgical Safety Checklist (SSC). Lewin’s change theory guided the project, and it was evaluated using the Donabedian Framework. The project uses a pre- and post- intervention approach. Targeted staff training and integration of SSC-guided TO were the interventions utilized. The data collection instrument was the weekly audit tool. Pre-implementation compliance was 20% (n = 6/30), and post- implementation adherence increased to 100% (n = 60/60). Fisher’s exact test demonstrated statistical significance (p < 0.01). The intervention improved adherence rate and workflow standardization. The QI project shows that staff training, leadership support, and implementation of SSC significantly improved adherence to the TO safety protocols in in-office procedural settings. Embedding SSC education into staff orientation and sustained auditing of TO adherence will support long-term adherence to safety protocols.
Rights Management
This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License
Recommended Citation
Osaremwinda, Funke, "Quality Improvement Project: Implementation of the Surgical Safety Checklist to Improve Adherence to Time-out at In-Office Procedure" (2026). Doctor of Nursing Practice Projects. 297.
https://arch.astate.edu/dnp-projects/297
