Back to Basics: The Universal Protocol

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1 CONTINUING EDUCATION Lisa Spruce, DNP, RN, CNS-CP, CNOR, ACNS, ACNP, FAAN CONTINUING EDUCATION CONTACT HOURS indicates that continuing education (CE) contact hours are available for this activity. Earn the CE contact hours by reading this article, reviewing the purpose/goal and objectives, and completing the online Examination and Learner Evaluation at content/cme. A score of 70% correct on the examination is required for credit. Participants receive feedback on incorrect answers. Each applicant who successfully completes this program can immediately print a certificate of completion. Event: #18502 Session: #0001 Fee: Free for AORN members. For non- member pricing, please visit The contact hours for this article expire January 31, Non- member pricing is subject to change. PURPOSE/GOAL To provide the learner with knowledge of best practices related to use of the Universal Protocol. OBJECTIVES 1. Discuss common areas of concern that relate to perioperative best practices. 2. Discuss best practices that could enhance safety in the perioperative area. 3. Describe implementation of evidence-based practice in relation to perioperative nursing care. ACCREDITATION AORN is accredited with distinction as a provider of continuing nursing education by the American Nurses Credentialing Center s Commission on Accreditation. APPROVALS This program meets criteria for CNOR and CRNFA recertification, as well as other CE requirements. AORN is provider- approved by the California Board of Registered Nursing, Provider Number CEP Check with your state board of nursing for acceptance of this activity for relicensure. CONFLICT- OF- INTEREST DISCLOSURES Lisa Spruce, DNP, RN, CNS- CP, CNOR, ACNS, ACNP, FAAN, has no declared affiliation that could be perceived as posing a potential conflict of interest in the publication of this article. The behavioral objectives for this program were created by Kristi Van Anderson, BSN, RN, CNOR, clinical editor, with consultation from Susan Bakewell, MS, RN- BC, director, Perioperative Education. Ms Van Anderson and Ms Bakewell have no declared affiliations that could be perceived as posing potential conflicts of interest in the publication of this article. SPONSORSHIP OR COMMERCIAL SUPPORT No sponsorship or commercial support was received for this article. DISCLAIMER AORN recognizes these activities as CE for RNs. This recognition does not imply that AORN or the American Nurses Credentialing Center approves or endorses products mentioned in the activity. 116 AORN Journal AORN, Inc, 2018

2 CLINICAL Lisa Spruce, DNP, RN, CNS-CP, CNOR, ACNS, ACNP, FAAN ABSTRACT Wrong- site, wrong- procedure, and wrong- person surgeries continue to occur in the United States. Perioperative team members must uphold patient safety as a top priority and implement safety measures to prevent these surgical errors. One such safety measure is the Universal Protocol, consisting of a preprocedure verification, site marking, time-out, and implementation of which is required by The Joint Commission and other regulatory bodies. This Back to Basics article describes the components of the Universal Protocol and some evidence- based strategies to implement it in practice. Key words: wrong-site, wrong-procedure, wrong-person surgery; sentinel event; time out; the Universal Protocol. Patients come to health care providers for help, to improve their health, and to find answers to their health- related questions. Patients come to the OR expecting to improve their health, to correct defects, to receive a diagnosis, to improve their quality of life, or to ease their pain. They expect to emerge from surgery with those expectations met; they do not expect to emerge from surgery to discover that the surgical team performed the wrong procedure or performed the procedure on the wrong site or side of their body. Nevertheless, wrong- site, wrong- procedure, and wrong- person surgical events continue to occur, and it is the responsibility of every health care worker and perioperative team member to prevent these potentially devastating and deadly events. Consider the following scenario as an example of how these events can occur and affect patients. A 45- yearold female patient, LT, is admitted to an outpatient surgery center to have a breast mass removed for biopsy. The surgeon marks the correct breast and the surgical team correctly identifies the patient preoperatively; however, the surgical team fails to perform a time out before beginning the procedure and does not confirm that the imaging displayed in the OR is for the correct patient or that it is relevant to the location of the patient s breast mass. After LT awakes in the postanesthesia care unit, she immediately sees her surgical dressing, calls the nurse over, and says this is not where my mass is, I know exactly where it is, I can feel it. Although this was not a wrong- side, wrongprocedure, or wrong- person surgery, the surgeon removed breast tissue from the wrong location in the breast. Although LT is not permanently injured and does not experience long- term consequences from this mistake, she must undergo another procedure to have the correct tissue removed and she loses faith in the health care system and in the surgical team. Additionally, the staff members involved in the procedure are formally disciplined, and the facility receives bad publicity and is investigated for compliance with accreditation standards. This scenario illustrates the importance of implementing a comprehensive, evidence- based approach to prevent these types of events from occurring. In response to the continued incidence of wrong- site, wrong- procedure, and wrong- person surgery in the United States, in 2004, The AORN, Inc, 2018 AORN Journal 117

3 Spruce January 2018, Vol. 107, No. 1 Joint Commission enacted the Universal Protocol for all of their accredited hospitals, outpatient surgery centers, and office- based surgery centers. 1 One component of the Universal Protocol is the requirement for surgical team members to perform a time out before beginning the procedure, which the surgical team did not complete in the scenario. There were 104 reported incidents of wrong-site, wrong-procedure, and wrong- person surgery in 2016 and 120 reported incidents in 2015, making it the second most frequently reported sentinel event for two consecutive years. Wrong- site, wrong- procedure, and wrong- person surgery is considered a sentinel event, which is an event that results in either death, permanent harm, or severe temporary harm and intervention required to sustain life. 2 Reporting sentinel events to The Joint Commission is voluntary, so data on their occurrence represent only a small proportion of the actual events that occur. There were 35 incidents of wrong- site, wrong- procedure, and wrong- person surgery reported to The Joint Commission as of the second quarter of There were 104 reported incidents of wrong-site, wrong-procedure, and wrong-person surgery in 2016 and 120 reported incidents in 2015, making it the second most frequently reported sentinel event for two consecutive years (both years it was preceded by incidents of unintended foreign-body retention). 3 HOW- TO GUIDE Use of the Universal Protocol is recommended by the World Health Organization in their Guidelines for Safe Surgery 4 and the components of the Universal Protocol are detailed in The Joint Commission s National Patient Safety Goals. 5 The Universal Protocol is based on the fact that wrong- site, wrong- procedure, and wrongperson surgery can and does happen and must be prevented. When patients undergo deep sedation or general anesthesia, they are at an increased risk for injury because they cannot participate in their own care or ensure their own safety. Perioperative team members should follow the Universal Protocol for all nonsurgical and surgical invasive procedures and complete each of its components: preprocedure verification, site marking, and time out. Preprocedure Verification The Universal Protocol specifies that health care providers at individual facilities can define the frequency and scope of the preprocedure verification process depending on the type of procedure and its complexity. 5 This process should be ongoing to ensure that the perioperative team is gathering and confirming critical patient information. The purpose of the preprocedure verification process is to ensure that all equipment, documents, and other essential information are available before the procedure begins; identified, matched, and labeled correctly with the patient s identifiers; and reviewed by the team and consistent with the patient s expectations and the team s understanding of the intended site, procedure, and patient. 5 The health care organization must determine when this information is collected and by whom, but it is best to involve the patient in the process. The information may be collected and verified at multiple points before the procedure, including when the procedure is scheduled, during preadmission testing and assessment, when the patient is admitted to the facility, and in the preoperative area before the patient enters the operating or procedure room. 5 The elements of performance of the preprocedure verification process are as follows: implement a process to confirm the correct procedure, patient, and site; identify the items that must be available for the surgery or procedure and use a standardized process to verify item availability; and match the available items to the patient AORN Journal

4 January 2018, Vol. 107, No. 1 The items that the surgical team should confirm are ready and available during the preprocedure verification include, at a minimum: documentation relevant to the surgery or procedure (eg, history and physical, surgical and anesthesia consent forms, preanesthesia assessment); proper display of labeled diagnostic and radiology test results (eg, biopsy reports, radiology images); and required implants, devices, blood products, and special equipment that are necessary to perform the procedure. 5 Site Marking The second component of the Universal Protocol requires the individual who knows the most about the patient (ie, the licensed independent practitioner who will be present during the procedure) to mark the patient s procedure site. 5 The facility s policy should specify the location and timing of the site marking, and the health care providers who create this policy should consider the facility s safety culture when designing the process. For example, it may be necessary for some facilities to be more prescriptive regarding certain elements or to add their own processes for compliance. 5 Site marking is not required if the individual who is performing the surgery or procedure is continuously with the patient from the decision to perform the procedure until the performance of the procedure. 5 The elements of performance for site marking are as follows: identify the procedures that will require a marking of the insertion or incision site; mark the procedure site before performing the procedure and involve the patient if possible; ensure that the procedure site is marked by a licensed independent practitioner who is accountable and will be present when the procedure is performed; ensure that site-marking protocol is consistent and unambiguous throughout the facility; and use an alternative written process for patients who refuse site marking or when it is anatomically or technically impossible or impractical to mark the site (eg, mucosal surfaces, perineum, teeth, minimal-access procedures involving a lateralized internal organ, premature infants for whom marking may cause a permanent tattoo). 5 When determining which procedures require a marked incision site to create a facility policy, clinicians should remember that, at a minimum, sites should be marked when there is more than one possible location for the procedure. For spinal procedures, in addition to marking the skin, the surgical team may use intraoperative imaging techniques to determine the exact vertebral level. The mark should be made at or near the procedure site and be sufficiently permanent to be visible after surgical skin antisepsis and draping. Adhesive markers should not be the sole means for surgical site marking, even if they are permitted by the facility. 5 When determining which procedures require a marked incision site to create a facility policy, clinicians should remember that, at a minimum, sites should be marked when there is more than one possible location for the procedure. There are limited circumstances that facility leaders should define in their facility s policy when a site marking may be delegated to an individual other than the licensed independent practitioner who will be present during the procedure. A delegate permitted to perform this task must be a medical postgraduate resident who is being supervised by the licensed independent practitioner performing the procedure, is familiar with the patient, and will be present during the surgery or procedure; or a licensed staff member who has a collaborative or supervisory agreement with the licensed independent practitioner performing the procedure, is familiar with the patient, and will be present during the surgery or procedure (eg, an advanced practice RN or physician assistant). 5 Time Out The last element of the Universal Protocol is to conduct a time out before the procedure begins. 5 The purpose of the AORN Journal 119

5 Spruce January 2018, Vol. 107, No. 1 Key Takeaways The Joint Commission enacted the Universal Protocol in 2004 as a response to the continued incidence of wrong-site, wrong-procedure, and wrong-person surgery in the United States. The Universal Protocol is comprised of three components that the surgical team must complete before a surgical procedure begins: preprocedure verification, site marking, and time out. Perioperative leaders should create policies to standardize the methods by which team members complete the elements of the Universal Protocol at their particular facility. Implementation of the Universal Protocol with full participation and engagement of all members of the perioperative team is essential for the prevention of critical patient safety events. time out is to perform a final check to ensure that the correct patient, correct site, and correct procedure are identified. During a time out, the entire surgical team should stop all activities so that the team can focus on the performance of the time out. Some facilities may require the team to perform a time out before anesthesia induction or sedation so that the patient may be involved. This type of time out may be performed on its own or in addition to another time out performed immediately before the incision is made. 5 The facility should designate a member of the team to initiate the time out and the rest of the surgical team should engage in the time- out process. 5 The procedure should not begin until all concerns and questions have been resolved. Time outs should be conducted in the same manner throughout the facility (ie, standardized across all procedural areas) to be most effective. 5 The elements of performance for a time out include a standardized process, defined by the facility, that is initiated by a designated team member and involves all members of the perioperative team; conducting the time out immediately before the procedure begins or before making the incision; conducting a time out before each separate procedure if two or more procedures are being performed on the same patient and the team member who is performing the additional procedure is different; at a minimum, agreement between all team members that the correct patient is undergoing the correct procedure at the correct surgical site; and documenting that the surgical team completed the time out as determined by the facility (ie, the facility determines the amount and type of documentation). 5 The participating team members should include the individual performing the procedure, the anesthesia care provider, RN circulator, scrub person or surgical technologist, and any other active team members who will be participating in the procedure from the beginning (eg, physician assistant). BENEFIT The Universal Protocol is an important and useful tool to reduce the incidence of wrong- site, wrong- procedure, and wrong- person surgeries. It is critical to protect patients and prevent these potentially devastating events from occurring. Zahiri et al 6 identified the preoperative period (ie, when the verification and time out are conducted) as a time when the surgical team can recognize and correct mistakes before they reach the patient. The researchers emphasized that the timeout process can be vulnerable to human error (eg, inaccurate or missing information) or lack full team participation. Additionally, even when time outs are executed properly, a wrong- site surgery can still occur. 6 Team members must be fully engaged participants in the time- out process so that the team can identify the patient, the procedure, and that all relevant aspects of the procedure or surgery are ready and correct (eg, antibiotics, venous thromboembolism prophylaxis). 6 Implementation of processes such as the Universal Protocol with full participation and engagement of all members of the perioperative team is essential for the prevention of critical patient safety events. STRATEGIES FOR SUCCESS A facility s approach to implementing the Universal Protocol should be robust and employ multiple evidence-based 120 AORN Journal

6 January 2018, Vol. 107, No. 1 strategies to promote the goal of always performing the correct procedure at the correct site on the correct person. 5 All perioperative team members should be actively involved and engaged in the process and use effective methods of team communication; patients and patients families should be involved when possible. 5 Facilities should standardize the methods by which team members use the Universal Protocol and include this process in the organization s policy (eg, identify the timing and location to perform the preprocedure verification and site marking based on the organization s own unique circumstances, needs, and patient population). 5 According to The Joint Commission, health care organizations that make patient safety a priority and promote teamwork, and in which perioperative team members are encouraged and empowered to speak up to protect patients, are the most successful at implementing the Universal Protocol. 5 Although some studies have demonstrated a decrease in the incidence of wrong- site, wrong- procedure, and wrongperson events after implementing Universal Protocol, these events still occur. 7,8 Paull et al 9 reviewed the database of the Veterans Affairs National Center for Patient Safety to determine the root cause of all procedures involving a wrong- site surgery between 2004 and 2013 to determine the frequency and characteristics of these events. The authors analyzed 308 events that occurred before and after the surgical team completed the Universal Protocol. Twenty- nine out of 48 wrong- surgery incidents occurred during intraocular implant surgeries, spinal procedures, prostatectomies, and excisions of malignant skin lesions. The procedures that resulted in harm to the patient were wrong- side orchiectomy, wrong- patient prostatectomy, and wrong- level neurosurgery. The root causes identified related to the events that occurred before performance of the Universal Protocol included mislabeling of radiographs and preoperative specimens and transposing pathology reports. Errors that occurred after performance of the Universal Protocol were wrong- level spine localization errors, intraoperative errors in diagnosing, and other intraoperative localization errors. The authors of this study recognized the value of the Universal Protocol, but also saw the need to expand the patient safety net. They offered the following strategies: verifying the correct level of surgery (eg, rib, vertebrae) using radiographic imaging; RESOURCES Correct Site Surgery Tool Kit. AORN. aorn.org/guidelines/clinical-resources/tool-kits/ correct-site-surgery-tool-kit. Accessed September 13, Doing the right things to correct wrong- site surgery. Patient Safety Authority. ADVISORIES/Pages/200706_29b.aspx. Published June Accessed September 13, Patient safety resources. American Academy of Ophthalmology. programs/patient-safety-resources. Accessed September 13, Patient safety topics: wrong- site surgery. Patient Safety Authority. Pages/Wrong%20Site%20Surgery/hm.aspx. Accessed September 13, Reducing the risks of wrong- site surgery: safety practices from The Joint Commission Center for Transforming Healthcare Project. American Hospital Association. ahahret-guides/1668. Accessed September 13, Resources to improve surgical care, reduce infections and wrong- site surgery. Center for Patient Safety. resources-to-improve-surgical-care-reduceinfections-and-wrong-site-surgery/. Published October 1, Accessed September 13, SafeStart: Start Surgery Safely. SafeStart Medical. Accessed September 13, SpeakUP. The Universal Protocol for Preventing Wrong Site, Wrong Procedure, and Wrong Person Surgery: Guidance for health care professionals. The Joint Commission. jointcommission.org/assets/1/18/up_poster1.pdf. Accessed September 13, Universal Protocol. The Joint Commission. up.aspx. Accessed September 13, Wrong site surgery. Joint Commission Center for Transfor ming Healthcare. centerfortransforminghealthcare.org/news/press/ wss.aspx. Accessed September 13, AORN Journal 121

7 Spruce January 2018, Vol. 107, No. 1 creating a standardized protocol to mark the correct skin lesion using preoperative photographs and verification of these photographs during the time-out process in addition to the site marking; standardizing the process for equipment calibration, performing measurements for implants during eye surgery, and creating a policy for preparation and transmission of lens implant calculations; clearing any labels and paperwork from any previous patient from the clinical area to prevent specimen mislabeling; and investing in technology to positively identify patients and specimens (eg, barcoding). 9 Another strategy to promote effective use of the Universal Protocol and to potentially decrease surgical errors is to use a surgical checklist. Surgical checklists lay out the tasks that the surgical team must complete before, during, and after surgery to help keep patients safe, and generally include the components of the Universal Protocol. Examples that perioperative teams may consider using include the World Health Organization s Surgical Safety Checklist 10 and AORN s Comprehensive Surgical Checklist (Supplementary Figure 1), which incorporates recommendations from the World Health Organization and The Joint Commission s Universal Protocol. 11 Surgical checklists have been associated with improved detection of safety hazards, decreased surgical complications, improved communication, and decreased morbidity and mortality. 12,13 WRAP- UP Wrong- site, wrong- procedure, and wrong- person events can and do happen. The first step toward prevention is for every perioperative team member to acknowledge that these events could happen; the perioperative team must then remain vigilant to prevent these events. By using the Universal Protocol and other tools (eg, surgical checklists), perioperative team members may decrease the potential for errors that could lead to a wrong- site surgery. Every perioperative team member is responsible for keeping patients safe and preventing events that harm patients. In addition to performing the Universal Protocol, team members can recognize risks to patient safety, speak up, and question what is occurring when necessary. It is important to engage in meaningful communication about the patient and the procedure during the time out. These elements combined with the Universal Protocol may help to keep patients safe from harm. Editor s notes: The Universal Protocol for Preventing Wrong Site, Wrong Procedure, and Wrong Person Surgery is a trademark of The Joint Commission, Oakbrook Terrace, IL. National Patient Safety Goals is a registered trademark of The Joint Commission on Accreditation of Healthcare Organizations, Oakbrook Terrace, IL. SUPPORTING INFORMATION Additional information may be found online in the supporting information tab for this article. REFERENCES 1. Universal Protocol for Preventing Wrong Site, Wrong Procedure, Wrong Person Surgery. Patient Safety Network. resource/3643. Published January Accessed September 13, Sentinel event policy and procedures. The Joint Commission. sentinel_event_policy_and_procedures/. Accessed September 13, Summary data of sentinel events reviewed by The Joint Commission. The Joint Commission. Summary_2Q_2017.pdf. Updated July 11, Accessed September 13, WHO Guidelines for Safe Surgery 2009: Safe Surgery Saves Lives. World Health Organization. who.int/iris/bitstream/10665/44185/1/ _eng.pdf. Accessed September 13, National Patient Safety Goals Effective January 1, The Joint Commission. jointcommission.org/assets/1/6/2015_npsg_hap. pdf. Accessed September 13, Zahiri HR, Stromberg J, Skupsky H, et al. Prevention of 3 never events in the operating room: fires, gossypiboma, and wrong- site surgery. Surg Innov. 2011;18(1): Vachhani JA, Klopfenstein JD. Incidence of neuro surgical wrong- site surgery before and 122 AORN Journal

8 January 2018, Vol. 107, No. 1 after implementation of the Universal Protocol. Neurosurgery. 2013;72(4): Hempel S, Maggard-Gibbons M, Nguyen DK, et al. Wrong- site surgery, retained surgical items, and surgical fires: a systematic review of surgical never events. JAMA Surg. 2015;150(8): Paull DE, Mazzia LM, Neily J, et al. Errors upstream and downstream to the Universal Protocol associated with wrong surgery events in the Veterans Health Administration. Am J Surg. 2015;210(1): Surgical Safety Checklist. Word Health Organization /2/ _eng_Checklist.pdf. Revised January Accessed September 13, Comprehensive Surgical Checklist. AORN. correct-site-surgery/aorn_comprehensive_surgical_ checklist_2016.pdf?la=en&hash=cfd d C593AAEB1044C773ED287DA. Updated June Accessed September 13, Treadwell JR, Lucas S, Tsou AY. Surgical checklists: a systematic review of impacts and implementation. BMJ Qual Saf. 2014;23(4): Borchard A, Schwappach DLB, Barbir A, Bezzola P. A systematic review of the effectiveness, compliance, and critical factors for implementation of safety checklists in surgery. Ann Surg. 2012;256(6): Lisa Spruce, DNP, RN, CNS- CP, CNOR, ACNS, ACNP, FAAN, is the director of Evidence- Based Perioperative Practice at AORN, Inc, Denver, CO. Dr Spruce has no declared affiliation that could be perceived as posing a potential conflict of interest in the publication of this article. LISTEN TO AORN JOURNAL ARTICLES ON THE GO If you ve always wanted to take the Journal with you to the gym, during your walking break, or on your commute, now you can! The Journal features special monthly podcasts that you can listen to online via the Journal web site or download directly to your preferred digital device. Each month, the Journal offers two full-length article podcasts and one brief overview podcast that highlights the articles in each issue. You can also access the podcasts via itunes or Google Play. To learn more about these access options and to view the Journal s complete collection of podcasts, visit AORN Journal 123

9 EXAMINATION Continuing Education PURPOSE/GOAL To provide the learner with knowledge of best practices related to use of the Universal Protocol. OBJECTIVES 1. Discuss common areas of concern that relate to perioperative best practices. 2. Discuss best practices that could enhance safety in the perioperative area. 3. Describe implementation of evidence-based practice in relation to perioperative nursing care. The Examination and Learner Evaluation are printed here for your convenience. To receive continuing education credit, you must complete the online Examination and Learner Evaluation at QUESTIONS 1. Wrong-site, wrong-procedure, and wrong-person surgery is considered a sentinel event, and was the second most frequently reported type of sentinel event in 2015 and 2016 according to The Joint Commission. a. true b. false 2. The components of the Universal Protocol are 1. time out. 2. preprocedure verification. 3. site marking. 4. skin antisepsis. a. 1 and 3 b. 2 and 4 c. 1, 2, and 3 d. 1, 2, 3, and 4 3. The team member who will be present during the procedure and who should be responsible for marking the patient s surgical site is the a. perioperative nurse. b. licensed independent practitioner. c. anesthesia care provider. d. medical student. 4. The time out should be performed a. immediately before making the incision. b. during preoperative verification. c. immediately before skin antisepsis. d. immediately before patient positioning. 5. Strategies to improve patient safety related to reducing the incidence of wrong-site, wrongprocedure, and wrong-person surgery include 1. clearing labels and paperwork from any previous patient from the clinical area. 2. using a surgical checklist. 3. verifying the correct level of surgery (eg, rib, vertebrae) using radiographic imaging. 4. creating a standardized protocol to mark the correct skin lesion using preoperative photographs. 5. investing in technology to positively identify patients and specimens. a. 1, 3, and 5 b. 2, 4, and 5 c. 2, 3, 4, and 6 d. 1, 2, 3, 4, and AORN Journal AORN, Inc, 2018

10 LEARNER EVALUATION Continuing Education This evaluation is used to determine the extent to which this continuing education program met your learning needs. The evaluation is printed here for your convenience. To receive continuing education credit, you must complete the online Examination and Learner Evaluation at cme. Rate the items as described below. OBJECTIVES To what extent were the following objectives of this continuing education program achieved? 1. Discuss common areas of concern that relate to perioperative best practices. Low High 2. Discuss best practices that could enhance safety in the perioperative area. Low High 3. Describe implementation of evidence-based practice in relation to perioperative nursing care. Low High CONTENT 4. To what extent did this article increase your knowledge of the subject matter? Low High 5. To what extent were your individual objectives met? Low High 6. Will you be able to use the information from this article in your work setting? 1. Yes 2. No 7. Will you change your practice as a result of reading this article? (If yes, answer question #7A. If no, answer question #7B.) 7A. How will you change your practice? (Select all that apply) 1. I will provide education to my team regarding why change is needed. 2. I will work with management to change/ implement a policy and procedure. 3. I will plan an informational meeting with physicians to seek their input and acceptance of the need for change. 4. I will implement change and evaluate the effect of the change at regular intervals until the change is incorporated as best practice. 5. Other: 7B. If you will not change your practice as a result of reading this article, why? (Select all that apply) 1. The content of the article is not relevant to my practice. 2. I do not have enough time to teach others about the purpose of the needed change. 3. I do not have management support to make a change. 4. Other: AORN, Inc, 2018 AORN Journal 125