Date of Award

Spring 5-2015

Degree Name

Doctor of Nursing Practice (DNP)

Committee Chair

Dr. Mary L. Coyne

Committee Chair Department


Committee Member 2

Dr. Patsy L. Anderson

Committee Member 2 Department



The purpose of this project was to utilize the ‘Institute for HealthCare Improvement’s Model of Improvement as a consultation framework to facilitate improvement in core processes for the prevention of wrong site surgery (WSS) using The Joint Commission Targeted Solutions Tool for Safe Surgery© Program at a surgery center in Mississippi. The TST Program was conducted across 6 months and had 6 phases: 1) Getting Started, 2) Training Data Collectors, 3) Measuring Risk Factors, 4) Analyzing Data, 5) Implementing Solutions, and 6) Sustaining the Gains. A convenience sample of 47 surgical staff participated and 8 data collectors observed behaviors. The nurse consultant, using the TST program assisted staff in reducing the risk of WSS from 16% to 9% in surgical booking, 86% to 53% in pre-op/holding, and 73% to 25% in the OR and empowered them to make 9 practice decisions (just-in-time coaching; improved communication between scheduling and pre-admissions; OR schedule fax back; primary documents within 48 hours before surgery; standardized patient verification; set up regional block time-out (TO) and role-based TO; standardized surgical site marking, and adoption of a surgical checklist). WSS is an avoidable event. Nurse consultants play a powerful role in enabling surgical staff to reexamine existing practice, change behavior, and create a culture of safety in reducing the risks of WSS and promoting patient safety.