ORIGINAL REPORTS Monitoring Universal Protocol Compliance Through Real-Time Clandestine Observation by Medical Students Results in Performance Improvement Catherine A. Logan, MSPT, Brienne D. Cressey, Roger Y. Wu, Adam J. Janicki, Cyril X. Chen, Meena L. Bolourchi, Jessica L. Hodnett, John D. Stratigis, William C. Mackey, MD, FACS, and David G. Fairchild, MD Department of Surgery, Tufts University Medical Center, Boston, Massachusetts OBJECTIVE: To measure universal protocol compliance through real-time, clandestine observation by medical students compared with chart audit reviews, and to enable medical stu- dents the opportunity to become conscious of the importance of medical errors and safety initiatives. DESIGN: With endorsement from Tufts Medical Center’s (TMC’s) Chief Medical Officer and Surgeon-in-Chief, 8 med- ical students performed clandestine observation audits of 98 cases from April to August 2009. A compliance checklist was based on TMC’s presurgical checklist. Our initial results led to interventions to improve our universal protocol procedures, including modifications to the operating room white board and presurgical checklist, and specific feedback to surgical depart- ments. One year later, 6 medical students performed observa- tions of 100 cases from June to August 2010. SETTING: Tufts Medical Center, Boston, Massachusetts, which is an academic medical center and the principal teaching hospital for Tufts University School of Medicine. PARTICIPANTS: An operating room coordinator placed the medical students into 1 of our 25 operating rooms with stu- dents entering under the premise of observing the anesthesiol- ogist for clinical education. The observations were performed Monday to Friday between 7 AM and 4 PM. Although observa- tions were not randomized, no single service or type of surgery was targeted for observation. RESULTS: A broad range of departments was observed. In 8.2% of cases, the surgical site was unmarked. A Time Out occurred in 89.7% of cases. The entire surgical team was atten- tive during the time out in 82% of cases. The presurgical check- list was incomplete before incision in 13 cases. Images were displayed in 82% of cases. The operating room “white board” was filled out completely in 49% of cases. Team introductions occurred in 13 cases. One year later, compliance increased in all Universal Protocol dimensions. CONCLUSIONS: Direct, real-time observation by medical students provides an accurate and granular assessment of com- pliance with specific components of the universal protocol and engages medical students in the quality improvement process, raises their awareness of the gravity of medical errors, and en- sures appreciation of the importance of quality and safety ini- tiatives. (J Surg 69:41-46. © 2012 Association of Program Di- rectors in Surgery. Published by Elsevier Inc. All rights reserved.) KEY WORDS: surgical education, universal protocol, medical errors, patient safety, checklist COMPETENCIES: Systems Based Practice, Practice Based Learning and Improvement, Professionalism INTRODUCTION Although deemed a “never event” by Centers for Medicare and Medicaid Services, the Joint Commission ranks wrong- site surgery (WSS) as the most frequently reported sentinel event with 666 instances, accounting for 13.7% of 4850 events between 2004 to 2010. 1 The Joint Commission is- sued Sentinel Event Alert newsletters regarding WSS in 1998 and 2001. The Universal Protocol aims to address the continuing occurrence of wrong-site, wrong-procedure, and wrong-person surgery in organizations accredited by the Joint Commission. It is composed of 3 principal compo- nents: conducting a preprocedure verification process, mark- ing the procedure site, and performing a time out before the Correspondence: Inquiries to Catherine A. Logan, MSPT, Department of Surgery, Tufts University School of Medicine, Tufts Medical Center, 800 Washington Street, Boston, MA 02111; e-mail: catherine.logan@tufts.edu Journal of Surgical Education • © 2012 Association of Program Directors in Surgery 1931-7204/$30.00 Published by Elsevier Inc. All rights reserved. doi:10.1016/j.jsurg.2011.05.015 41