Table 3. Specific Examples of Improvements by Category.

Category	Examples of corrections
Organization
Revision of existing policies	Revised policies to better reflect WHO Surgical Safety Checklist, Joint Commission National Patient Safety Goals standards, and AORN: Management of the Environment of Care Sponge Count Outside consultation to assess safety culture and provide recommendations for policy revision
Education of revised policy	Education of revised policy via emails to physicians Review policy changes during operating room huddles Formal hands-on training required if new technology or process adopted
Reeducation of current policy
Policy adherence monitoring	Review of documentation Direct observation of policy or protocol Disciplinary warnings or actions if training not achieved within time frame
Surgical checklist revision or adoption	Revised checklist to better reflect WHO Surgical Safety Checklist Revised checklist to better reflect Joint Commission National Patient Safety Goals standards
Disciplinary actions	Restriction of physician operative privileges Disciplinary warnings and termination if nonadherent
Verification of surgical site and marking of the site	Review of imaging, reports, and preoperative history to verify surgical site Require presentation of imaging in the operating room before incision Team consensus on surgical site before incision
Interpersonal communication
Verbal or audible timeout revised	Require all staff and physicians to pause for timeout Review deficiencies concerning timeout policy Timeout script developed and implemented Nurse looking in medical record, reading through script for each procedure Ensure visibility of surgical site during timeout Verbal confirmation of surgical site by each member of the team
Formal teaching to improve communication	Strategies and Tools to Enhance Performance and Patient Safety curriculum training (ahrq.gov) Situation, Background, Assessment, Recommendation Assertiveness training for staff Emails to surgeons to update policies regarding communication between anesthesia and staff
Confirm patient, procedure, or incision site with patient	Site marked while the patient is in preoperative room Confirm site and procedure with patient and/or family
Verbal announcement of sponge or instrument placement or removal	Decrease ambient noise during count Staff training to improve communication and assertiveness Speak Up for Patient Safety training
Written communication of instrument counts	Visible whiteboard in operating room Intraoperative documentation of instrument counts in electronic record whenever instruments are counted
Verbal announcement of completed count	Pause while final count in progress Final closing count undertaken by scrub tech and nurse before completion of skin closure Surgeon verbally confirms completed count Radiography used if cannot reconcile count Avoid wound packing with towels or sponges
Tools, technology, and skills
Procurement of new equipment	Install racks to hold used sponges to improve organization of sponges and ease of counting Use of radiofrequency sponges Check patient’s body cavity with radiofrequency wand if counts are incorrect Adopt electronic sponge tracking system
Competency validation by direct observation	Assess individual competency, identify individual weaknesses, and allow for immediate corrective action Annual competency reevaluation for surgical counts
Hands-on training	Hands-on training of new count procedures, including use of new instrument counting technologies
Passive training	Lecture using AORN materials Handouts and emails with policy changes
Setting equipment to safety standards	Turn off all open oxygen sources for at least 1 min before using electrical surgical unit or other ignition source. If oxygen cannot be turned off, it should be decreased to minimal possible setting while maintaining patient oxygen saturation. Use nasal cannula instead of face mask when possible. Review xiphoid draping process to prevent trapping of pooled oxygen Confirm power settings before use Keep power at lowest settings

Abbreviations: AORN, Association of Perioperative Registered Nurses; WHO, World Health Organization.