To Comment:

1. Discuss the difference between external and internal evidence as it relates to your PICOT search strategy.

Internal Evidences regarding Universal Protocol or "Surgical Time out" or "Surgical Pause" are embedded in the organization's policies and procedures as mandated by the Joint Commission. The Quality Improvement Department or Risk Management have written directives on the implementation of the 3 components of the Universal Protocol which include 1) Pre-op or pre-procedure verification, 2) Site marking and 3)

Surgical time out or pause before the incision (Dixon et al, 2017). Noncompliance to the policies and procedures that result to minor or lethal consequences are compiled in incident reports, near misses and sentinel event records. Wrong Site Surgery (WSS), wrong patient and wrong procedure are the common errors tackled during root cause analysis sessions to eliminate surgical errors and improve the safety process. These are substantial internal evidences that are available for use in my PICOT research.

External evidences of the Universal Protocol are systematic investigations which are the byproducts of rigorous studies that are typically conducted by the federal, national and local organizations to use across clinical settings. The Joint Commission mandated the Universal Protocol in partnership with the Association of Operating Room Nurses to eliminate surgical errors (Conrardy et al, 2010). The American Association of Orthopedic Surgeons and other private sectors like the insurance companies joined them in their quest for "never events" that are preventable.

One example of external evidence on Universal Protocol are the researches by clinician-investigators such as intensivist Peter Pronovost and surgeons Atul Gawande and Martin Makary. Their clinical studies and investigations have been instrumental in clarifying that communication issues among the patient care teams result in errors during medical and surgical interventions. They introduced the idea of checklists to eliminate errors and eventually save lives.

They were the biggest proponents of "speaking up" when there is a discrepancy in patient care (Berlinger,2016). These result to quality indicators which are used by the insurance companies to "pay for performance" as an incentive to continually improve patient outcomes.

2. Address the strengths and weaknesses of searching in a databank versus a web-based search engine. You must use two databanks mentioned in the text.

Web based engines sponsored by the professional organizations, like Medline, PubMed and CINAHL have researches meant for the medical and nursing fields which filter out extraneous studies making research productive and fulfilling - personally and professionally. It contains vast indexes of significant evidence based practice that could be reviewed for clinical application.

The web based engines have a wide variety and quantity of information that is sophisticated enough to pull the data that precisely describe the keyword and phrases. This strength could be a weakness when it pulls information that is irrelevant to your topic. When this occurs, research could be exhausting that could lead to frustration and discouragement.

On the other side of the spectrum we have national databanks for another source of external evidences. One of them is the National Strategy for Quality Improvement in Health Care which was created the Department of Health and Human Services. This promote not only the data collection but also the implementation strategies for the different sectors of the community.

Their main goals are 1) To improve patient experience and satisfaction, 2) Improve health of the general population and 3) Reduce health costs. This databank gives innovating organization's name, the adoption consideration, the planning and evidence rating, contact information and other references. Another national databank worth mentioning is the National Quality Forum (NQF).

NQF is a nonprofit organization that developed and implemented a national strategy to measure and report health care quality indicators (ex. universal protocols in ambulatory centers). NDQ has provided a forum for the stakeholders with diverse objectives to sit together to discuss, question and develop measures on contentious areas (Hoflund,2013). It is designed to experiment on healthcare issues by addressing them from different stakeholder's perception.

The strengths of these 2 national databanks are1) transparency in their reporting sites where2) comparative data could be reviewed and examined. They are 3) updated on a consistent basis making them a great source of evidence based information with evidence based rating. Validity, reliability and applicability of evidence based practices could make this national databank information weak or strong for certain patient population.