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The recognition, change and establishment of systems to promote patient safety and mitigate risk of harm has been well recognized for almost a decade, certainly since the dissemination of information in the publication, To Err is Human: Building a Safer Health System (Institute of Medicine,1999).  More recently, the pace of that change is likely to accelerate, particularly in implementation of electronic health records, diffusion of safe practices, team training, and full disclosure to patients following injury (Leape & Berwick, 2005).  The growing sophistication of computers and software should allow information technology to play a vital part in reducing that risk — by streamlining care, catching and correcting errors, assisting with decisions, and providing feedback on performance (Bates & Gawande, 2003).

In the obstetrical unit of Catholic Medical Center antidotal reports from medical and nursing staff stated compliance with surgical patient safety initiatives. In actuality, compliance was not consistent and several random observations of procedures appreciated the paper record was not capturing the actual practice.  The following will describe the methods and evaluation of the transition from surgical paper documentation of “Universal Protocol” to an electronic intra-operative record specific for cesarean births. Even though it was obvious our current documentation practice was not optimal, changing the documentation practices was challenging. To help guide the process, Lewin’s Stages of Change model (Lewin, 1952) was used to framework the process.

One of the main reasons that some clinical applications are not progressing to widespread use is that the clinicians were not involved in their development or selection (Anonymous, 2008). As well, previous research suggests that nurses often feel constrained in their ability to communicate with physicians (Gardezt, et. al, 2009). To mitigate those barriers in decision making and communication, nursing collaborated with the medical, surgical, quality and information technology staff in the building of the new electronic documentation.  Once completed, education and demonstrations were provided to all staff impacted by the new change in practice. 

Implementing the electronic record resulted in immediate improvement in compliance with the Universal Protocol. This was felt to be directly related to the ease of access of the software and ability to do real-time charting in the operating room. A decrease in post surgical complication was also noted. Continued evaluation and quality monitoring will further determine sustained quality and practice improvements.