Date of Completion


Document Type

Open Access Capstone

Degree Name

Doctor of Nursing Practice (DNP)

Faculty Advisor

Eileen Stuart-Shor

Site Advisor

Patrice Osgood

Second Reader

Linda J. Curtin


Background: Decreasing the risk of wrong site, wrong procedure and wrong patient surgery is an essential healthcare safety initiative. The Joint Commission’s Universal Protocol along with the World Health Organization (WHO) Safe Surgery Checklist were designed to aid in this patient safety effort and have been implemented in hospitals worldwide.

Local Problem: Perioperative and procedural areas at the project hospital areas have adopted the Universal Protocol and Safe Surgery Checklist. Despite agreement in their importance, there is a lack of uniform application of all components. This leads to variation in practice which may impact team compliance with the protocol and patient safety if critical components of the process are missed.

METHODS: A review of the literature revealed standardization of the universal protocol process as an evidence-based, promising intervention to decrease variability across perioperative and procedural areas. The overarching aim was to evaluate current practice of the universal protocol process in procedural and perioperative areas, identify gaps, and design a hospital-wide, standardized approach to universal protocol.

INTERVENTION: The intervention was executed in 3 phases. Phase 1 evaluated current universal protocol tools and practice in procedural and perioperative areas and identified gaps. Phase 2 convened a working group of nursing experts from each project area to design a standardized process consisting of critical elements for each phase of the universal protocol. Phase 3 obtained consensus agreement and approval for the hospital wide dissemination of the recommended standardized process and tool from all area stakeholders.

RESULTS: Analysis of universal protocol tools and direct observation of practice illustrated wide variation in the universal protocol process across 12 perioperative and procedural areas at the project hospital. These findings supported project approval by perioperative and procedural stakeholders for the development and implementation of the standardized universal protocol process and tool.

CONCLUSION: This project demonstrated that it is feasible to standardize universal protocol practice across 12 complex and diverse perioperative and procedural settings. The effective use of the Kotter change theory engaged essential stakeholders and provided the foundation for the acceptance and completion of the project aims.