Graduation Semester and Year

Fall 2026

Language

English

Document Type

DNP Project

Degree Name

Doctor of Nursing Practice

Department

Nursing

First Advisor

Cathy Brown

Abstract

Background: Sterile instrumentation is critical to preventing surgical site infections (SSIs). Approximately 3% of U.S. patients experience an SSI, resulting in significant costs and potential patient harm. Regulatory audits also frequently identify deficiencies in sterile processing, instrument compliance, and equipment quality. Standardized workflows can help reduce errors, lower SSI risk, and improve outcomes.

Objective: This quality improvement project aims to reduce regulatory findings identified through surgical instrument audits by implementing a perioperative process bundle.

Methods: Three hospitals within a large healthcare organization piloted a bundle focused on: (1) appropriate point-of-use processes, (2) reducing time between instrument use and cleaning, and (3) proper equipment use during instrument handling. Staff education and department-specific checklists reinforced bundle adherence. Regular audits measured instrument compliance.

Results: Two of the three hospitals demonstrated improved compliance with sterilization cleanliness standards.

Conclusion: Bundle compliance and process standardization are achievable but depend on hospital size and staff engagement. Continuous quality improvement remains essential for healthcare leaders seeking tailored solutions to persistent operational challenges.

Keywords

SSI, Joint Commission, SPD, Sterile instruments, Bundle, Cleanliness, Perioperative, Quality improvement, EBP

Disciplines

Nursing | Nursing Administration | Other Nursing | Perioperative, Operating Room and Surgical Nursing

Comments

Thank you to Dr. Cathy Brown for her tireless dedication and mentorship. 

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