Quick answer
On the infection control leadership team at Avon Surgery Center, Jaleh Saghafi, RN, identified an infection-control concern involving surgical marking pens. She wrote revised policies and taught them to nursing staff and about 15 attending physicians and residents. Compliance rose from 30% to 100% and stayed at 100% for three consecutive quarters. She reported the results each quarter to the Vice President of Nursing.
This page walks through the initiative step by step. It also explains why small items like a surgical marking pen matter in infection prevention, and what the result shows about leading change in a clinical setting.
The results at a glance
| Measure | Result |
|---|---|
| Compliance before the initiative | 30% |
| Compliance after the initiative | 100% |
| How long 100% was sustained | Three consecutive quarters |
| Clinicians trained | Nursing staff, plus about 15 attending physicians and residents |
| How physician sign-off was documented | Acknowledgment by email |
| Reporting | Quarterly, to the Vice President of Nursing |
Why surgical marking pens matter
Before many procedures, the surgical site is marked on the patient’s skin with a pen. Marking is a patient-safety step that helps make sure the procedure is done in the right place. But the pen touches skin near the area where an incision will be made. That makes how marking pens are used and handled a question of infection control, not just supplies.
Infection prevention in surgery depends on many small, consistent habits. No single habit stops every infection. Standardizing each one lowers the overall risk for patients. The U.S. Centers for Disease Control and Prevention describes surgical site infections and how to prevent them on its surgical site infection basics page.
How the initiative worked
- Identify the gap. Saghafi identified the marking-pen infection-control concern while working on the facility’s infection control leadership team.
- Write the fix. She developed revised policies and coordinated how they would be put in place across clinical stakeholders.
- Teach it to everyone who touches it. She presented the revised procedures to nursing staff and to about 15 attending physicians and residents.
- Document agreement. She obtained documented acknowledgment from physicians by email, so there was a record that each one had received the change.
- Measure and report. She monitored performance and reported results each quarter to the Vice President of Nursing.
- Sustain it. Compliance reached 100% and stayed there for three consecutive quarters.
Broader infection-control work
The marking-pen project was one part of a larger role. At Avon Surgery Center, Saghafi led infection-control work across two surgical facilities, covering:
- Medication audits
- Staff education
- Regulatory compliance
- Patient-safety standards
She also worked in the PACU (post-anesthesia care unit). There she educated patients on medications, pain management, post-procedure care and what to expect during recovery.
What the result shows
Moving a practice from 30% to 100% compliance means changing the daily habits of people with different roles and priorities: surgeons, residents, anesthesia providers and nurses. The steps above give each of those groups a clear policy, direct teaching, a documented commitment and visible measurement. Holding 100% for three quarters shows that the change lasted.
Infection prevention for patients at home
Infection prevention continues after a patient leaves the surgery center. For practical guidance written for patients and caregivers, read Caring for a Surgical Incision at Home.
Related: clinical and patient education · full experience