Towards better patient safety: WHO Surgical Safety Checklist in otorhinolaryngology

Facilitators and barriers to the implementation of surgical safety checklist: an integrative review

Surgical procedures pose an immense risk to patients, which can lead to various complications and adverse events. In order to safeguard patients' safety, the World Health Organization initiated the implementation of the Surgical Safety Checklist (SSC) in operating theatres worldwide. The aim of this integrative review was to summarize and evaluate the use and implementation of SSC, focusing on facilitators and barriers at the individual, professional, and organizational levels. This review followed closely the integrative review method by Whittemore and Knafl. An English literature search was conducted across three electronic databases (PubMed, CINAHL, and EMBASE) and other hand search references. Keywords search included: 'acute care', 'surgical', 'adult patients', 'pre-operative', 'intra-operative', and 'post-operative'. A total of 816 articles were screened by two reviewers independently and all articles that met the pre-specified inclusion criteria were retained. Data extracted from the articles were categorized, compared, and further analysed. A total of 34 articles were included with the majority being observational studies in developed and European countries. Checklists had been adopted in various surgical specialities. Findings indicated that safety checklists improved team cohesion and communication, resulting in enhanced patient safety. This resulted in high compliance rates as healthcare workers expressed the benefits of SSC to facilitate safety within operating theatres. Barriers included manpower limitations, hierarchical culture, lack of staff involvement and training, staff resistance, and appropriateness of checklist. Common facilitators and barriers at individual, professional, and organizational levels have been identified. Staff training and education, conducive workplace culture, timely audits, and appropriate checklist adaptations are crucial components for a successful implementation of the SSC. Methods have also been introduced to counter barriers of SSC.

Implementation of World Health Organization behaviorally anchored rating scale and checklist utilization: promising results for LMICs

BACKGROUND

Operating teams can decrease the likelihood of patient risk by using the WHO Surgical Safety Checklist. To ascertain the impact of demographic factors on behaviorally anchored ratings and investigate operating room (OR) staff attitudes toward checklist administration, we set out to better understand how OR personnel use the checklist in a tertiary care hospital in Pakistan.

MATERIALS AND METHODS

A monocentric sequential mixed-methods study employing a quantitative approach of using World Health Organization Behaviorally Anchored Rating Scale (WHOBARS) assessments of surgical cases by OR personnel and two independent observers, who were certified surgeons having extensive experience in the rating of the WHOBARS scale for more than 1 year, followed by a qualitative approach of staff interviews were carried out in a tertiary care setting. In June and July 2022, over the period of 8 weeks, an intervention (training delivery) was implemented and evaluated. The information, skills, and behavior adjustments required to apply the checklist were taught in the course using lectures, videos, small group breakouts, participant feedback, and simulations.

RESULTS

After the introduction of WHOBARS, 50.81% of respondents reported always using the checklist, with another 30.81% using it in part. Participants' years in practice, hospital size, or surgical volume did not predict checklist use. Checklist use was associated with always counting instruments (51.08%), patient identity (67.83%), difficult intubation risk (39.72%), the risk of blood loss (51.08%), prophylactic administration of an antibiotic (52.43%), and the use of pulse oximeter (46.75%). Interviewees felt that the checklist could promote teamwork and a safe culture, particularly enabling speaking up. Senior staff were of key importance in setting the appropriate tone.

CONCLUSION

The use of a multi-disciplinary course for checklist implementation resulted in 50.81% of participants always using the checklist and an increase in counting surgical instruments. Successful checklist implementation was not predicted by the participant's length of medical service, hospital size, or surgical volume. If reproducible in other countries, widespread implementation in LMICs becomes a realistic possibility.

Surgical safety checklists for dental implant surgeries-a scoping review

OBJECTIVES

In both elective surgeries and aviation, a reduction of complications can be expected by paying attention to the so-called human factors. Checklists are a well-known way to overcome some of these problems. We aimed to evaluate the current evidence regarding the use of checklists in implant dentistry.

METHODS

An electronic literature search was conducted in the following databases: CINHAL, Medline, Web of Science, and Cochrane Library until March 2022. Based on the results and additional literature, a preliminary checklist for surgical implant therapy was designed.

RESULTS

Three publications dealing with dental implants and checklists were identified. One dealt with the use of a checklist in implant dentistry and was described as a quality assessment study. The remaining two studies offered suggestions for checklists based on literature research and expert opinion.

CONCLUSIONS

Based on our results, the evidence for the use of checklists in dental implantology is extremely low. Considering the great potential, it can be stated that there is a need to catch up. While creating a new implant checklist, we took care of meeting the criteria for high-quality checklists. Future controlled studies will help to place it on a broad foundation.

CLINICAL RELEVANCE

Checklists are a well-known way to prevent complications. They are especially established in aviation, but many surgical specialties and anesthesia adopt this successful concept. As implantology has become one of the fastest-growing areas of dentistry, it is imperative that checklists become an integral part of it.

A standardized marking procedure for ENT operations to prevent wrong-site surgery: development, establishment and subsequent evaluation among patients and medical personnel

Purpose

Wrong-site surgeries are rare but potentially serious clinical errors. Marking the surgical site is crucial to preventing errors, but is hindered in the ENT field by the presence of many internal organs. In addition, there is no standardized marking procedure.

Methods

Here, an ENT surgical-marking procedure was developed and introduced at a clinic. The procedure was evaluated through anonymized questionnaires. This study was conducted over a 6-month period by interviewing patients and, at the beginning and end of this period, doctors and other surgical staff.

Results

The internal organ-marking problem was solved by applying a fixed abbreviation for each procedure onto the shoulder in addition to marking the skin surface as close to the organ as possible. The procedure was described as practicable by 100% of the interviewees; 75% of the ENT physicians and 96.3% of the other surgical staff considered the procedure highly important for preventing site confusion, and 75% of the physicians had a consequently greater feeling of safety. Of the 248 patients surveyed, 96.0% considered the marking procedure useful, and 75.8% had a consequently greater feeling of safety. For 52.0%, the marking reduced their fear of the operation.

Conclusions

For the first time, a standardized procedure was developed to mark the site of ENT surgery directly, uniformly and safely on patients. The procedure was judged to be useful and practicable and was also deemed crucial for preventing site confusion. Patients felt safer and less fearful of the operation due to the marking.

Safety Checklists for Emergency Response Driving and Patient Transport: Experiences from Emergency Medical Services

BACKGROUND

Emergency response driving (ERD) is considered one of the most significant occupational risk factors affecting both patient and traffic safety in emergency medical services (EMS). The majority of the risk factors in ERD are crew related and could be affected positively with crew resource management (CRM). The aim of this study was to examine how the safety checklists developed for ERD and patient transport are experienced in practical work in EMS by paramedics.

METHODS

Safety checklists for ERD and patient transport were developed and then piloted in practical work among 30 paramedics in five different EMS areas around Finland for a two-month period in fall 2019. Afterward, semistructured thematic interviews were performed with the pilot participants, and the material was analyzed using inductive content analysis.

RESULTS

Paramedics experienced that use of ERD and patient transport safety checklists improved safety, and deployment of the checklists required systematic planning. Use of the safety checklists was seen as changing the mindset of the ERD drivers to a more safety critical stance and increasing a systematic approach to ERD. Paramedics also stated that when deploying the checklists in EMS, their use should be standardized as a nationwide operating model and that service-dependent fine-tuning is required.

CONCLUSION

This study's findings support the use of ERD and patient transport safety checklists in practical work in EMS for promoting safety. In addition to safety checklists, other sections of CRM and its applications to EMS should also be studied.

Interventions to improve team effectiveness within health care: a systematic review of the past decade

BACKGROUND

A high variety of team interventions aims to improve team performance outcomes. In 2008, we conducted a systematic review to provide an overview of the scientific studies focused on these interventions. However, over the past decade, the literature on team interventions has rapidly evolved. An updated overview is therefore required, and it will focus on all possible team interventions without restrictions to a type of intervention, setting, or research design.

OBJECTIVES

To review the literature from the past decade on interventions with the goal of improving team effectiveness within healthcare organizations and identify the "evidence base" levels of the research.

METHODS

Seven major databases were systematically searched for relevant articles published between 2008 and July 2018. Of the original search yield of 6025 studies, 297 studies met the inclusion criteria according to three independent authors and were subsequently included for analysis. The Grading of Recommendations, Assessment, Development, and Evaluation Scale was used to assess the level of empirical evidence.

RESULTS

Three types of interventions were distinguished: (1) Training, which is sub-divided into training that is based on predefined principles (i.e. CRM: crew resource management and TeamSTEPPS: Team Strategies and Tools to Enhance Performance and Patient Safety), on a specific method (i.e. simulation), or on general team training. (2) Tools covers tools that structure (i.e. SBAR: Situation, Background, Assessment, and Recommendation, (de)briefing checklists, and rounds), facilitate (through communication technology), or trigger (through monitoring and feedback) teamwork. (3) Organizational (re)design is about (re)designing structures to stimulate team processes and team functioning. (4) A programme is a combination of the previous types. The majority of studies evaluated a training focused on the (acute) hospital care setting. Most of the evaluated interventions focused on improving non-technical skills and provided evidence of improvements.

CONCLUSION

Over the last decade, the number of studies on team interventions has increased exponentially. At the same time, research tends to focus on certain interventions, settings, and/or outcomes. Principle-based training (i.e. CRM and TeamSTEPPS) and simulation-based training seem to provide the greatest opportunities for reaching the improvement goals in team functioning.

Clinical Indices to Drive Quality Improvement in Otolaryngology

A Pediatric Tracheostomy Care Index (PTCI) was developed by the authors to standardize care and drive quality improvement efforts at their institution. The PTCI comprises 9 elements deemed essential for safe care of children with a tracheostomy tube. Based on the PTCI scores, the number of missed opportunities per patient was tracked, and interventions through a "Plan-Do-Study-Act" approach were performed. The establishment of the PTCI has been successful at standardizing, quantifying, and monitoring the consistency and documentation of care provided at the authors' institution.

Implementation of the surgical safety checklist in hospitals of Iran; operating room personnel's attitude, awareness and acceptance

Purpose The WHO Surgical Safety Checklist (SSC) has improved patient safety effectively. Despite the known benefits of applying the checklist before surgery, its implementation is less than universal in practice. The purpose of this paper is to determine the operating room personnel's attitude, their awareness and knowledge of the SSC, and to evaluate staff acceptance of the SSC (including personal beliefs). Design/methodology/approach This cross-sectional study was conducted in eight tertiary general hospitals in Tehran, Iran. Some 145 operating room personnel (surgeons, anaesthetists and nurses) were selected for the study. Data collection was carried out via a validated questionnaire in three parts which included socio-demographic, attitude, awareness and acceptance. Data were then analysed using the Kruskal-Wallis and χ² statistical test. Findings Out of the 145 participants in the study, 92 per cent were aware of the existence of the SSC and 73.9 per cent of them were aware of the objectives of SSC. Overall, the attitude to SSC was positive. The attitude of surgeons was positive towards the impact of the SSC on safety and teamwork. Surgeons were significantly more sensitive to the barriers of SSC application compared to nurses and anaesthetists ( p=0.046). Among the three groups, nurses had the highest level of support for SSC ( p=0.001). Practical implications Despite high acceptance of the checklist among staff, there is still a gap in knowledge about when exactly the checklist should be used. Therefore, involvement of all surgical team members to complete the checklist process, support of senior managers, on-going education and training and consideration of the barriers to its implementation are all key areas that need to be taken into account. Originality/value This is the first research to examine the operating room personnel's attitude, awareness and acceptance about SSC in Iranian hospitals. The outcomes of this study provide documentation and possible justification for effective establishment of SSC in Iran and other countries.

Surgical Safety Checklists in Children's Surgery: Surgeons' Attitudes and Review of the Literature

Supplemental Digital Content is available in the text.

Introduction:

Surgical safety checklists (SSCs) aim to create a safe operating room environment for surgical patients. Provider attitudes toward checklists affect their ability to prevent harm. Pediatric surgeons’ perceptions surrounding SSCs, and their role in improving patient safety, are unknown.

Methods:

American Pediatric Surgical Association members conducted an online survey to evaluate the use of and attitudes toward SSCs. The survey measured surgeons’ perceptions of checklists, including the components that make them effective and barriers to participation. To better evaluate the available data on SSCs, the authors performed a systematic literature review on the use of SSCs with a focus on pediatric studies.

Results:

Of the 353 survey respondents, 93.6% use SSCs and 62.6% would want one used in their own child’s operation, but only 54.7% felt that checklists improve patient safety. Reasons for checklist skepticism included the length of the checklist process, a distraction from thoughtful patient care, and lack of data supporting use. Literature review shows that checklists improve communication, promote teamwork, and identify errors, but do not necessarily decrease morbidity. Staff perception is a major barrier to implementation.

Conclusions:

Almost all pediatric surgeons participate in SSCs at their institutions, but many question their benefit. Better pediatric surgeon engagement in checklist use is needed to change the safety culture, improve operating room communication, and prevent harm.

A challenge-response endoscopic sinus surgery specific checklist as an add-on to standard surgical checklist: an evaluation of potential safety and quality improvement issues

BACKGROUND

The goal of this study was to develop and evaluate the impact of an aviation-style challenge and response sinus surgery-specific checklist on potential safety and equipment issues during sinus surgery at a tertiary academic health center. The secondary goal was to assess the potential impact of use of the checklist on surgical times during, before, and after surgery. This initiative is designed to be utilized in conjunction with the "standard" World Health Organization (WHO) surgical checklist. Although endoscopic sinus surgery is generally considered a safe procedure, avoidable complications and potential safety concerns continue to occur. The WHO surgical checklist does not directly address certain surgery-specific issues, which may be of particular relevance for endoscopic sinus surgery.

METHODS

This prospective observational pilot study monitored compliance with and compared the occurrence of safety and equipment issues before and after implementation of the checklist. Forty-seven consecutive endoscopic surgeries were audited; the first 8 without the checklist and the following 39 with the checklist. The checklist was compiled by evaluating the patient journey, utilizing the available literature, expert consensus, and finally reevaluation with audit type cases. The final checklist was developed with all relevant stakeholders involved in a Delphi method.

RESULTS

Implementing this specific surgical checklist in 39 cases at our institution, allowed us to identify and rectify 35 separate instances of potentially unsafe, improper or inefficient preoperative setup. These incidents included issues with labeling of topical vasoconstrictor or injectable anesthetics (3, 7.7%) and availability, function and/or position of video monitors (2, 5.1%), endoscope (6, 15.4%), microdebrider (6, 15.4%), bipolar cautery (6, 15.4%), and suctions (12, 30.8%).

CONCLUSION

The design and integration of this checklist for endoscopic sinus surgery, has helped improve efficiency and patient safety in the operating room setting.

Evaluation and Customization of WHO Safety Checklist for Patient Safety in Otorhinolaryngology

The WHO has designed a safe surgery checklist to enhance communication and awareness of patient safety during surgery and to minimise complications. WHO recommends that the check-list be evaluated and customised by end users as a tool to promote safe surgery. The aim of present study was to evaluate the impact of WHO safety checklist on patient safety awareness in otorhinolaryngology and to customise it for the speciality. A prospective structured questionnaire based study was done in ENT operating room for duration of 1 month each for cases, before and after implementation of safe surgery checklist. The feedback from respondents (surgeons, nurses and anaesthetists) was used to arrive at a customised checklist for otolaryngology as per WHO guidelines. The checklist significantly improved team member's awareness of patient's identity (from 17 to 86%) and each other's identity and roles (from 46 to 94%) and improved team communication (from 73 to 92%) in operation theatre. There was a significant improvement in preoperative check of equipment and critical events were discussed more frequently. The checklist could be effectively customised to suit otolaryngology needs as per WHO guidelines. The modified checklist needs to be validated by otolaryngology associations. We conclude from our study that the WHO Surgical safety check-list has a favourable impact on patient safety awareness, team-work and communication of operating team and can be customised for otolaryngology setting.

Effectiveness and meaningful use of paediatric surgical safety checklists and their implementation strategies: a systematic review with narrative synthesis

OBJECTIVE

To examine the effectiveness and meaningful use of paediatric surgical safety checklists (SSCs) and their implementation strategies through a systematic review with narrative synthesis.

SUMMARY BACKGROUND DATA

Since the launch of the WHO SSC, checklists have been integrated into surgical systems worldwide. Information is sparse on how SSCs have been integrated into the paediatric surgical environment.

METHODS

A broad search strategy was created using Pubmed, Embase, CINAHL, Cochrane Central, Web of Science, Science Citation Index and Conference Proceedings Citation Index. Abstracts and full texts were screened independently, in duplicate for inclusion. Extracted study characteristic and outcomes generated themes explored through subgroup analyses and idea webbing.

RESULTS

1826 of 1921 studies were excluded after title and abstract review (kappa 0.77) and 47 after full-text review (kappa 0.86). 20 studies were of sufficient quality for narrative synthesis. Clinical outcomes were not affected by SSC introduction in studies without implementation strategies. A comprehensive SSC implementation strategy in developing countries demonstrated improved outcomes in high-risk surgeries. Narrative synthesis suggests that meaningful compliance is inconsistently measured and rarely achieved. Strategies involving feedback improved compliance. Stakeholder-developed implementation strategies, including team-based education, achieved greater acceptance. Three studies suggest that parental involvement in the SSC is valued by parents, nurses and physicians and may improve patient safety.

CONCLUSIONS

A SSC implementation strategy focused on paediatric patients and their families can achieve high acceptability and good compliance. SSCs' role in improving measures of paediatric surgical outcome is not well established, but they may be effective when used within a comprehensive implementation strategy especially for high-risk patients in low-resource settings.

Time-Out and Checklists: A Survey of Rural and Urban Operating Room Personnel

Surgical safety checklists were introduced to improve patient safety. Urban and rural hospitals are influenced by differing factors, but how these factors affect patient care is unknown. This study examined time-out and checklist processes in rural and urban operating rooms and found that although checklist use has been adopted in many organizations, use is inconsistent across both settings. An understanding of these variations is needed to improve utilization.

Using a Checklist in Robotic-Assisted Laparoscopic Radical Prostatectomy Procedures

Robotic surgical systems are relatively new in New Zealand and have been used mainly for laparoscopic radical prostatectomy. Checklists are successfully used in other industries and health care facilities, so we developed a checklist for use during robotic-assisted laparoscopic radical prostatectomy (RALRP) procedures. After a two-month trial using the checklist, we calculated the completeness of each phase of the checklist as a percentage of the number of completed checklists versus total number of compliant checklists in that phase. Operating room personnel participated in an audiotaped focus group and discussed their perceptions about using the RALRP checklist. We collected, transcribed, and reviewed the focus group discussion and thematically analyzed the responses, which confirmed that the checklist served as a guideline and reminder during the setup. Additionally, staff members associated the checklist with improved OR readiness, minimized workflow interruption, improved efficiency, and positive changes in confidence and teamwork.

Patient safety in nursing paths in Brazil

Objective:

summarize the dissertations and theses produced by nurses available in the Catalog of Theses and Dissertations of the Brazilian Nursing Association, from volume XIX to XXXII, that address patient safety.

Method:

this is a documentary study. After data collection, the following variables were analyzed: academic level, educational institutions, year, place, type of service, study object, study method, subjects, priority protocol of patient safety, implications and final recommendations.

Results:

8,720 abstracts were found, 53 (0.61%) of which were analyzed. There was a predominance of dissertations (n=19; 35.85%) regarding the reduction of risks for fall and pressure ulcer (n=24; 45.28%), of descriptive type (n=21; 39.62%), quantitative type (n=16; 30.19%), in hospital environments (n=16; 30.19%), using scales and protocols (n=6; 11.32%).

Conclusion:

there is a tendency towards the development of studies related to patient safety in hospital environments, with an emphasis on the reduction of risk for pressure ulcer.

Perioperative Safety in Plastic Surgery: Is the World Health Organization Checklist Useful in a Broad Practice?

INTRODUCTION

In October 2007, the World Health Organization (WHO) introduced the Safe Surgery Saves Lives Program, the cornerstone of which was a 19-item safe-surgery checklist (SSC), in 8 selected hospitals around the world. After implementation, death rates decreased significantly from 1.5% to 0.8% (P = 0.003), inpatient complications reduced from 11% to 7% (P < 0.001), as did rates of surgical site infection (P < 0.001) and wrong-sided surgery (P < 0.47), across all sites. On the basis of these impressive reductions in complications and mortality, our institution adopted the WHO SSC in April 2009, with a few additional measures included, such as assuring presence of appropriate implants and administration of preoperative antibiotics and thromboembolic prophylaxis. Our purpose was to evaluate the efficacy and applicability of the surgical safety checklist in a multisurgeon plastic surgery hospital-based practice, by analyzing its effect on morbidity and outcomes.

METHODS

A retrospective review of the morbidity and mortality data from the Department of Plastic Surgery at Loma Linda University Medical Center was conducted from January 2006 to July 2012. Data on morbidity and mortality before and after implementation of the surgical safety checklist were analyzed.

RESULTS

The most common complications were wound related, including infection, seroma and/or hematoma, dehiscence, and flap-related complications. No significant decrease in the measured complications, neither total nor each specific complication, occurred after the implementation of the SSC. Although verifying appropriate administration of antibiotic, presence of appropriate equipment and materials, performing a preoperative formal pause, and verifying the execution of the other measures included in the SSC is critical, untoward outcomes after implementation of the checklist did not measurably decrease. In its current form as this time, the checklist does not seem to be efficacious in Plastic Surgery.

CONCLUSIONS

Although certain elements of the WHO SSC checklist are universal and should be adopted, certain specific aspects require modification to improve applicability in a plastic surgery-specific practice. This necessitates the creation of a surgical safety checklist specifically for plastic surgery as other surgical specialties have proposed.

Impact of Checklist Use on Wellness and Post-Elective Surgery Appointments in a Veterinary Teaching Hospital

Cognitive functioning is often compromised with increasing levels of stress and fatigue, both of which are often experienced by veterinarians. Many high-stress fields have implemented checklists to reduce human error. The use of these checklists has been shown to improve the quality of medical care, including adherence to evidence-based best practices and improvement of patient safety. Although it has been recognized that veterinary medicine would likely demonstrate similar benefits, there have been no published studies to date evaluating the use of checklists for improving quality of care in veterinary medicine. The purpose of the current study was to evaluate the impact of checklists during wellness and post-elective surgery appointments conducted by fourth-year veterinary students within their Community Practice rotation at a US veterinary teaching hospital. Students were randomly assigned to one of two groups: those who were specifically asked to use the provided checklists during appointments, and those who were not asked to use the checklists but had them available. Two individuals blinded to the study reviewed the tapes of all appointments in each study group to determine the amount and type of medical information offered by veterinary students. Students who were specifically asked to use the checklists provided significantly more information to owners, with the exception of keeping the incision clean. Results indicate the use of checklists helps students provide more complete information to their clients, thereby potentially enhancing animal care.

Patient safety in otolaryngology: a descriptive review

Human evaluation and judgement may include errors that can have disastrous results. Within medicine and healthcare there has been slow progress towards major changes in safety. Healthcare lags behind other specialised industries, such as aviation and nuclear power, where there have been significant improvements in overall safety, especially in reducing risk of errors. Following several high profile cases in the USA during the 1990s, a report titled "To Err Is Human: Building a Safer Health System" was published. The report extrapolated that in the USA approximately 50,000 to 100,000 patients may die each year as a result of medical errors. Traditionally otolaryngology has always been regarded as a "safe specialty". A study in the USA in 2004 inferred that there may be 2600 cases of major morbidity and 165 deaths within the specialty. MEDLINE via PubMed interface was searched for English language articles published between 2000 and 2012. Each combined two or three of the keywords noted earlier. Limitations are related to several generic topics within patient safety in otolaryngology. Other areas covered have been current relevant topics due to recent interest or new advances in technology. There has been a heightened awareness within the healthcare community of patient safety; it has become a major priority. Focus has shifted from apportioning blame to prevention of the errors and implementation of patient safety mechanisms in healthcare delivery. Type of Errors can be divided into errors due to action and errors due to knowledge or planning. In healthcare there are several factors that may influence adverse events and patient safety. Although technology may improve patient safety, it also introduces new sources of error. The ability to work with people allows for the increase in safety netting. Team working has been shown to have a beneficial effect on patient safety. Any field of work involving human decision-making will always have a risk of error. Within Otolaryngology, although patient safety has evolved along similar themes as other surgical specialties; there are several specific high-risk areas. Medical error is a common problem and its human cost is of immense importance. Steps to reduce such errors require the identification of high-risk practice within a complex healthcare system. The commitment to patient safety and quality improvement in medicine depend on personal responsibility and professional accountability.

[Establishment of a modified surgical safety checklist for the neurosurgical patient: Initial experience in 400 cases]

INTRODUCTION

Adverse events during diagnostic and therapeutic procedures and medical errors associated with them are an important source of patient morbidity. In an attempt to reduce these, the WHO has proposed a series of measures applicable to medical and surgical patients. Within these last ones is the surgical safety checklist (SSC), a brief questionnaire that does not increase healthcare costs, is accessible to all surgical centres and can be adapted to each specific environment.

OBJECTIVES

To evaluate the effectiveness of establishing a modified WHO SSC on the safety and quality of care of the neurosurgical patient in a third-level university hospital.

MATERIAL AND METHODS

The SSC was applied to a series of 400 scheduled surgeries between May 2009 and May 2010. During the initial 6 months, 183 surgical procedures were performed (group 1). All adverse events detected in this period were studied with a root-cause analysis methodology (RCA) and, according to its results, corrective measures were introduced. After that, 217 procedures were performed (group 2).

RESULTS

We recorded 51 events in 44 surgeries (11%). We were able to correct 88.23% of them before surgery was initiated, avoiding any consequence in the normal management of the case. In Group 1, incidents were noted in 15.3% of the procedures. The RCA suggested that 37.8% of the events had a human cause, followed by problems related to material resources and equipment in 29.7%, and organisational reasons in 21.6%. Incidence of events was reduced in group 2 to 7.4% (P=.01). Corrective measures prevented the appearance of perioperative events in 1 out of 13 procedures.

CONCLUSIONS

The SSC is an effective tool for improving safety in neurosurgical patients, which can be established in surgical departments of any hospital without increasing healthcare costs or operative time.

Compliance and Surgical Team Perceptions of WHO Surgical Safety Checklist; Systematic Review

This systematic review aimed to assess surgical safety checklist compliance and evaluate surgical team perceptions and attitudes, post-checklist implementation in the operating room. The World Health Organization (WHO) surgical safety checklist (SSC) has decreased complications and mortality. However, it is unclear whether this reduction is influenced by the vicarious enhancement in teamwork, communication, and staff awareness established by SSC implementation. The preferred reporting items for systematic reviews and meta-analyses model of review guided a search across MEDLINE, PubMed, and Embase databases. English-language studies using any adapted form of the WHO-SSC in operating rooms were reviewed by abstract and full text. Twenty-six studies, 13 assessing SSC compliance and 13 investigating surgical team perceptions of SSC, were evaluated. Compliance studies showed a checklist initiation rate of &gt;90%, but actual observed completion rate varied widely across studies. Sign out was the most poorly performed phase of the checklist (&lt;50%) with time out being the best. Verification of patient identity and procedure demonstrated a high degree (&gt;90%) of compliance across studies, but “verification of team-members” was significantly less compliant. Studies assessing surgical team perceptions found that SSC improved participants' perception of teamwork, communication, patient safety, and staff awareness of adverse events. However, when stakeholders placed differing degrees of importance on SSC completion, results indicated the SSC might actually antagonize team relationships. SSC compliance varies significantly across studies, being highly dependent on staff perceptions, training, and effective leadership. Surgical teams have positive perceptions of SSC; thus with effective implementation strategies, compliance rates across all phases can be substantially improved.

A realist analysis of hospital patient safety in Wales: applied learning for alternative contexts from a multisite case study

Background

Hospital patient safety is a major social problem. In the UK, policy responses focus on the introduction of improvement programmes that seek to implement evidence-based clinical practices using the Model for Improvement, Plan-Do-Study-Act cycle. Empirical evidence that the outcomes of such programmes vary across hospitals demonstrates that the context of their implementation matters. However, the relationships between features of context and the implementation of safety programmes are both undertheorised and poorly understood in empirical terms.

Objectives

This study is designed to address gaps in conceptual, methodological and empirical knowledge about the influence of context on the local implementation of patient safety programmes.

Design

We used concepts from critical realism and institutional analysis to conduct a qualitative comparative-intensive case study involving 21 hospitals across all seven Welsh health boards. We focused on the local implementation of three focal interventions from the 1000 Lives+patient safety programme: Improving Leadership for Quality Improvement, Reducing Surgical Complications and Reducing Health-care Associated Infection. Our main sources of data were 160 semistructured interviews, observation and 1700 health policy and organisational documents. These data were analysed using the realist approaches of abstraction, abduction and retroduction.

Setting

Welsh Government and NHS Wales.

Participants

Interviews were conducted with 160 participants including government policy leads, health managers and professionals, partner agencies with strategic oversight of patient safety, advocacy groups and academics with expertise in patient safety.

Main outcome measures

Identification of the contextual factors pertinent to the local implementation of the 1000 Lives+patient safety programme in Welsh NHS hospitals.

Results

An innovative conceptual framework harnessing realist social theory and institutional theory was produced to address challenges identified within previous applications of realist inquiry in patient safety research. This involved the development and use of an explanatory intervention–context–mechanism–agency–outcome (I-CMAO) configuration to illustrate the processes behind implementation of a change programme. Our findings, illustrated by multiple nested I-CMAO configurations, show how local implementation of patient safety interventions are impacted and modified by particular aspects of context: specifically, isomorphism, by which an intervention becomes adapted to the environment in which it is implemented; institutional logics, the beliefs and values underpinning the intervention and its source, and their perceived legitimacy among different groups of health-care professionals; and the relational structure and power dynamics of the functional group, that is, those tasked with implementing the initiative. This dynamic interplay shapes and guides actions leading to the normalisation or the rejection of the patient safety programme.

Conclusions

Heightened awareness of the influence of context on the local implementation of patient safety programmes is required to inform the design of such interventions and to ensure their effective implementation and operationalisation in the day-to-day practice of health-care teams. Future work is required to elaborate our conceptual model and findings in similar settings where different interventions are introduced, and in different settings where similar innovations are implemented.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

[Are the measures to ensure patient safety in surgery evidence-based?]

Errors occurring in surgical procedures often have serious consequences for the patients. For this reason various measures have been designed over the past few years to ensure a greater level of patient safety in surgery. One such measure is the implementation of the WHO safety checklist in German hospitals. The benefits of this checklist on postoperative complications have been substantiated by evidence from EbM level II studies and meta-analyses. The application of further tools such as the systematic rating of hospitals in terms of defined operative procedures would appear theoretically rational, but has not been demonstrated by studies with a higher level of evidence.

Attitudes towards the surgical safety checklist and factors associated with its use: A global survey of frontline medical professionals

BACKGROUND

The Surgical Safety Checklist (SSC) has been shown to reduce perioperative errors and complications and its implementation is recommended by the World Health Organisation (WHO). However, it is unknown how widely this intervention is used. We investigated attitudes and factors associated with use of WHO SSC in frontline medical professionals across the globe using a survey distributed through social networks.

METHODS

A survey of usage and opinions regarding the SSC was posted on the Facebook and Twitter pages of a not-for-profit surgical news website for one month (March 2013). Respondents were grouped into four groups based on their country's Gross National Income: high, upper middle, lower middle and low income. Univariate and multivariate analyses were performed to investigate how different factors were associated with the use of the SSC.

RESULTS

6269 medical professionals from 69 countries responded to the survey: most respondents were from lower middle (47.4%) countries, followed by: high (35.0%), upper middle (14.6%), and low (3.0%) income countries. In total, 57.5% reported that they used the WHO SSC perioperatively. Fewer respondents used the WHO SSC in upper middle, lower middle and low income countries (LMICs) compared to high income countries (43.5% vs. 83.5%, p < 0.001). Female (61.3% vs. 56.4% males, p = 0.001), consultant surgeons (59.6% vs. 53.2% interns, p < 0.001) and working in university hospitals (61.4% vs. 53.7% non-university hospitals, p < 0.001) were more likely to use the SSC. Believing the SSC was useful, did not work or caused delays was independently associated with the respondents reported use of the SSC (OR 1.22 95% CI 1.07-1.39; OR 0.47 95% CI 0.36-0.60; OR 0.64 95% CI 0.53-0.77, respectively).

CONCLUSION

This study suggests the use of the WHO SSC is variable across countries, especially in LMICs where it has the most potential to improve patient safety. Critical appraisal of the documented benefits of the WHO SSC may improve its adoption by those not currently using it.

Surgical checklists: a systematic review of impacts and implementation

BACKGROUND

Surgical complications represent a significant cause of morbidity and mortality with the rate of major complications after inpatient surgery estimated at 3-17% in industrialised countries. The purpose of this review was to summarise experience with surgical checklist use and efficacy for improving patient safety.

METHODS

A search of four databases (MEDLINE, CINAHL, EMBASE and the Cochrane Database of Controlled Trials) was conducted from 1 January 2000 to 26 October 2012. Articles describing actual use of the WHO checklist, the Surgical Patient Safety System (SURPASS) checklist, a wrong-site surgery checklist or an anaesthesia equipment checklist were eligible for inclusion (this manuscript summarises all but the anaesthesia equipment checklists, which are described in the Agency for Healthcare Research and Quality publication).

RESULTS

We included a total of 33 studies. We report a variety of outcomes including avoidance of adverse events, facilitators and barriers to implementation. Checklists have been adopted in a wide variety of settings and represent a promising strategy for improving the culture of patient safety and perioperative care in a wide variety of settings. Surgical checklists were associated with increased detection of potential safety hazards, decreased surgical complications and improved communication among operating staff. Strategies for successful checklist implementation included enlisting institutional leaders as local champions, incorporating staff feedback for checklist adaptation and avoiding redundancies with existing systems for collecting information.

CONCLUSIONS

Surgical checklists represent a relatively simple and promising strategy for addressing surgical patient safety worldwide. Further studies are needed to evaluate to what degree checklists improve clinical outcomes and whether improvements may be more pronounced in particular settings.

Introduction of surgical safety checklists in Ontario, Canada

BACKGROUND

Evidence from observational studies that the use of surgical safety checklists results in striking improvements in surgical outcomes led to the rapid adoption of such checklists worldwide. However, the effect of mandatory adoption of surgical safety checklists is unclear. A policy encouraging the universal adoption of checklists by hospitals in Ontario, Canada, provided a natural experiment to assess the effectiveness of checklists in typical practice settings.

METHODS

We surveyed all acute care hospitals in Ontario to determine when surgical safety checklists were adopted. Using administrative health data, we compared operative mortality, rate of surgical complications, length of hospital stay, and rates of hospital readmission and emergency department visits within 30 days after discharge among patients undergoing a variety of surgical procedures before and after adoption of a checklist.

RESULTS

During 3-month periods before and after adoption of a surgical safety checklist, a total of 101 hospitals performed 109,341 and 106,370 procedures, respectively. The adjusted risk of death during a hospital stay or within 30 days after surgery was 0.71% (95% confidence interval [CI], 0.66 to 0.76) before implementation of a surgical checklist and 0.65% (95% CI, 0.60 to 0.70) afterward (odds ratio, 0.91; 95% CI, 0.80 to 1.03; P=0.13). The adjusted risk of surgical complications was 3.86% (95% CI, 3.76 to 3.96) before implementation and 3.82% (95% CI, 3.71 to 3.92) afterward (odds ratio, 0.97; 95% CI, 0.90 to 1.03; P=0.29).

CONCLUSIONS

Implementation of surgical safety checklists in Ontario, Canada, was not associated with significant reductions in operative mortality or complications. (Funded by the Canadian Institutes of Health Research.).

Improving the preoperative care of patients with femoral neck fractures through the development and implementation of a checklist

The incidence of femoral neck fractures (FNFs) is expected to rise with life expectancy. It is important to improve the safety of these patients whilst under the care of orthopaedic teams.

This study aimed to increase the performance of vital preoperative tasks in patients admitted for femoral neck fracture operations by producing and implementing a checklist as an aide memoir. The checklist was designed primarily for use by senior house officers (SHOs) admitting patients from the emergency department.

A list of 12 preoperative tasks was identified. A baseline audit of 10 random patients showed that the mean proportion of the 12 tasks completed was 53% (range 25% - 83%). A survey of 14 nurses and surgeons found that the majority of respondents agreed that there was a problem with the performance of most of the tasks. The tasks were incorporated into a checklist which was refined in three plan-do-study-act cycles and introduced into the femoral neck fracture pathway.

In the week following the introduction of the checklist, 77% of the checklist tasks were completed, 24% more than at the baseline audit (53%). In week 3, the completion of checklist tasks rose to 88% and to 95% in week 4.

In conclusion, a simple checklist can markedly improve the performance and recording of preoperative tasks by SHOs. We recommend the wider adoption of the new checklist to be produced as a sticker for patients’ medical records. Further study is required to ascertain the effect of the checklist on clinical outcomes.

Do safety checklists improve teamwork and communication in the operating room? A systematic review

OBJECTIVES

The aim of this systematic review was to assess the impact of surgical safety checklists on the quality of teamwork and communication in the operating room (OR).

BACKGROUND

Safety checklists have been shown to impact positively on patient morbidity and mortality following surgery, but it is unclear whether this clinical improvement is related to an improvement in OR teamwork and communication.

METHODS

A systematic search strategy of MEDLINE, EMBASE, PsycINFO, Google Scholar, and the Cochrane Database for Systematic Reviews was undertaken to obtain relevant articles. After de-duplication and the addition of limits, 315 articles were screened for inclusion by 2 researchers and all articles meeting a set of prespecified inclusion criteria were retained. Information regarding the type of checklist, study design, assessment tools used, outcomes, and study limitations was extracted.

RESULTS

Twenty articles formed the basis of this systematic review. All articles described an empirical study relating to a case-specific safety checklist for surgery as the primary intervention, with some measure of change/improvement in teamwork and/or communication relating to its use. The methods for assessing teamwork and communication varied greatly, including surveys, observations, interviews, and 360° assessments. The evidence suggests that safety checklists improve the perceived quality of OR teamwork and communication and reduce observable errors relating to poor team skills. This is likely to function through establishing an open platform for communication at the start of a procedure: encouraging the sharing of critical case-related information, promoting team coordination and decision making, flagging knowledge gaps, and enhancing team cohesion. However, the evidence would also suggest that when used suboptimally or when individuals have not bought in to the process, checklists may conversely have a negative impact on the function of the team.

CONCLUSIONS

Safety checklists are beneficial for OR teamwork and communication and this may be one mechanism through which patient outcomes are improved. Future research should aim to further elucidate the relationship between how safety checklists are used and team skills in the OR using more consistent methodological approaches and utilizing validated measures of teamwork such that best practice guidelines can be established.

The effects of safety checklists in medicine: a systematic review

BACKGROUND

Safety checklists have become an established safety tool in medicine. Despite studies showing decreased mortality and complications, the effects and feasibility of checklists have been questioned. This systematic review summarises the medical literature aiming to show the effects of safety checklists with a number of outcomes.

METHODS

The Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) statement was used. All studies in which safety checklists were used as an additional tool designed to assure that an operation or task was performed as planned were included.

RESULTS

The initial search extracted 7408 hits. Twenty-nine articles met the inclusion criteria. Five additional studies were identified by a cross-referencing search. Four groups were made according to outcome measures. One group (n = 7) had 'hard' outcome measures, such as mortality and morbidity. The remaining studies, reporting 'softer' process-related measures, were divided into three categories: adherence to guidelines (n = 6), human factors (n = 16), and reduction of adverse events (n = 5). The main findings were improved communication, reduced adverse events, better adherence to standard operating procedures, and reduced morbidity and mortality. None of the included studies reported decreased patient safety or quality after introducing safety checklists.

CONCLUSION

Safety checklists appear to be effective tools for improving patient safety in various clinical settings by strengthening compliance with guidelines, improving human factors, reducing the incidence of adverse events, and decreasing mortality and morbidity. None of the included studies reported negative effects on safety.

Surgical safety checklist is associated with improved operating room safety culture, reduced wound complications, and unplanned readmissions in a pilot study in neurosurgery

BACKGROUND AND AIMS

The World Health Organization's surgical safety checklist is designed to improve adherence to operating room safety standards, and its use has been shown to reduce complications among surgical patients. The objective of our study was to assess the impact of the implementation of the checklist on safety-related issues in the operating room and on postoperative adverse events in neurosurgery.

MATERIAL AND METHODS

From structured questionnaires delivered to operating room personnel, answers were analyzed to evaluate communication and safety-related issues during 89 and 73 neurosurgical operations before and after the checklist implementation, respectively. From the analyzed operations, 83 and 67 patients, respectively, were included in a retrospective analysis of electronic patient records to compare the length of hospital stay, reported adverse events, and readmissions. In addition, the consistency of operating room documentation and patient records was assessed.

RESULTS AND CONCLUSIONS

Communication between the surgeon and the anesthesiologist was enhanced, and safety-related issues were better covered when the checklist was used. Unplanned readmissions fell from 25% to 10% after the checklist implementation (p = 0.02). Wound complications decreased from 19% to 8% (p = 0.04). The consistency of documentation of the diagnosis and the procedure improved. The use of the checklist improved safety-related performance and, contemporarily, reduced numbers of wound complications, and readmissions were observed.

Meta-analysis of surgical safety checklist effects on teamwork, communication, morbidity, mortality, and safety

The purpose of this study is to examine the effectiveness of surgical safety checklists on teamwork, communication, morbidity, mortality, and compliance with safety measures through meta-analysis. Four meta-analyses were conducted on 19 studies that met the inclusion criteria. The effect size of checklists on teamwork and communication was 1.180 (p = .003), on morbidity and mortality was 0.123 (p = .003) and 0.088 (p = .001), respectively, and on compliance with safety measures was 0.268 (p < .001). The results indicate that surgical safety checklists improve teamwork and communication, reduce morbidity and mortality, and improve compliance with safety measures. This meta-analysis is limited in its generalizability based on the limited number of studies and the inclusion of only published research. Future research is needed to examine possible moderating variables for the effects of surgical safety checklists.

Clinical Practice Guideline

Objective

Thyroidectomy may be performed for clinical indications that include malignancy, benign nodules or cysts, suspicious findings on fine needle aspiration biopsy, dysphagia from cervical esophageal compression, or dyspnea from airway compression. About 1 in 10 patients experience temporary laryngeal nerve injury after surgery, with longer lasting voice problems in up to 1 in 25. Reduced quality of life after thyroid surgery is multifactorial and may include the need for lifelong medication, thyroid suppression, radioactive scanning/treatment, temporary and permanent hypoparathyroidism, temporary or permanent dysphonia postoperatively, and dysphagia. This clinical practice guideline provides evidence-based recommendations for management of the patient’s voice when undergoing thyroid surgery during the preoperative, intraoperative, and postoperative period.

Purpose

The purpose of this guideline is to optimize voice outcomes for adult patients aged 18 years or older after thyroid surgery. The target audience is any clinician involved in managing such patients, which includes but may not be limited to otolaryngologists, general surgeons, endocrinologists, internists, speech-language pathologists, family physicians and other primary care providers, anesthesiologists, nurses, and others who manage patients with thyroid/voice issues. The guideline applies to any setting in which clinicians may interact with patients before, during, or after thyroid surgery. Children under age 18 years are specifically excluded from the target population; however, the panel understands that many of the findings may be applicable to this population. Also excluded are patients undergoing concurrent laryngectomy. Although this guideline is limited to thyroidectomy, some of the recommendations may extrapolate to parathyroidectomy as well.

Results

The guideline development group made a strong recommendation that the surgeon should identify the recurrent laryngeal nerve(s) during thyroid surgery. The group made recommendations that the clinician or surgeon should (1) document assessment of the patient’s voice once a decision has been made to proceed with thyroid surgery; (2) examine vocal fold mobility, or refer the patient to a clinician who can examine vocal fold mobility, if the patient’s voice is impaired and a decision has been made to proceed with thyroid surgery; (3) examine vocal fold mobility, or refer the patient to a clinician who can examine vocal fold mobility, once a decision has been made to proceed with thyroid surgery if the patient’s voice is normal and the patient has (a) thyroid cancer with suspected extrathyroidal extension, or (b) prior neck surgery that increases the risk of laryngeal nerve injury (carotid endarterectomy, anterior approach to the cervical spine, cervical esophagectomy, and prior thyroid or parathyroid surgery), or (c) both; (4) educate the patient about the potential impact of thyroid surgery on voice once a decision has been made to proceed with thyroid surgery; (5) inform the anesthesiologist of the results of abnormal preoperative laryngeal assessment in patients who have had laryngoscopy prior to thyroid surgery; (6) take steps to preserve the external branch of the surperior laryngeal nerve(s) when performing thyroid surgery; (7) document whether there has been a change in voice between 2 weeks and 2 months following thyroid surgery; (8) examine vocal fold mobility or refer the patient for examination of vocal fold mobility in patients with a change in voice following thyroid surgery; (9) refer a patient to an otolaryngologist when abnormal vocal fold mobility is identified after thyroid surgery; (10) counsel patients with voice change or abnormal vocal fold mobility after thyroid surgery on options for voice rehabilitation. The group made an option that the surgeon or his or her designee may monitor laryngeal electromyography during thyroid surgery. The group made no recommendation regarding the impact of a single intraoperative dose of intravenous corticosteroid on voice outcomes in patients undergoing thyroid surgery.

Surgical checklists: the human factor

BACKGROUND

Surgical checklists has been shown to improve patient safety and teamwork in the operating theatre. However, despite the known benefits of the use of checklists in surgery, in some cases the practical implementation has been found to be less than universal. A questionnaire methodology was used to quantitatively evaluate the attitudes of theatre staff towards a modified version of the World Health Organisation (WHO) surgical checklist with relation to: beliefs about levels of compliance and support, impact on patient safety and teamwork, and barriers to the use of the checklist.

METHODS

Using the theory of planned behaviour as a framework, 14 semi-structured interviews were conducted with theatre personnel regarding their attitudes towards, and levels of compliance with, a checklist. Based upon the interviews, a 27-item questionnaire was developed and distribute to all theatre personnel in an Irish hospital.

RESULTS

Responses were obtained from 107 theatre staff (42.6% response rate). Particularly for nurses, the overall attitudes towards the effect of the checklist on safety and teamworking were positive. However, there was a lack of rigour with which the checklist was being applied. Nurses were significantly more sensitive to the barriers to the use of the checklist than anaesthetists or surgeons. Moreover, anaesthetists were not as positively disposed to the surgical checklist as surgeons and nurse. This finding was attributed to the tendency for the checklist to be completed during a period of high workload for the anaesthetists, resulting in a lack of engagement with the process.

CONCLUSION

In order to improve the rigour with which the surgical checklist is applied, there is a need for: the involvement of all members of the theatre team in the checklist process, demonstrated support for the checklist from senior personnel, on-going education and training, and barriers to the implementation of the checklist to be addressed.

Wrong site surgery in otolaryngology-head and neck surgery

OBJECTIVES/HYPOTHESIS

Wrong site surgery has received high public awareness this past decade, yet discussion specific to otolaryngology is limited.

STUDY DESIGN

Literature review.

METHODS

We searched the MEDLINE database on PubMed from 1980 to 2013 and pursued the citations of key references further. We conducted a review of the literature and public patient safety reports on the scope, root causes, and prevention of wrong site surgery with emphasis on otolaryngology.

RESULTS

A review of the literature reveals that otolaryngology procedures constitute 0.3% to 4.5% of all wrong site surgery events, and wrong site surgery accounts for 4% to 6% of all medical errors in otolaryngology. A significant proportion (9% to 21%) of otolaryngologists reported experiences with wrong site surgery over their career, and the events most frequently resulted in temporary injuries to the patient with few cases of permanent disability or death. Although otolaryngology procedures have similar root causes for wrong site events as other specialties, inverted imaging and ambiguity in site marking are particular challenges. Site-marking practices are variable among otolaryngologists, as it is not applicable to many otolaryngology procedures, yet these are common procedures that also constitute the majority of wrong site cases reported in otolaryngology.

CONCLUSIONS

Future interventions to address these challenges related to otolaryngology-head and neck surgery might involve a standardized protocol to confirm imaging accuracy, a specialty- or procedure-specific checklist, a standardized alternative to site marking when marking is impractical, and other innovations. Evaluation of these interventions is becoming easier given the increasing mandatory reporting of these events that provides more reliable incidence data.

Surgical safety checklists: a review

BACKGROUND

Surgical checklists are designed to improve patient outcomes following surgery. While such checklists have been widely implemented worldwide, few studies examine surgical checklists within an Australian context. For this purpose, we have performed a literature review using data from OECD member nations to determine the effectiveness of surgical checklists in improving patient outcomes and factors that contribute to their successful implementation.

METHOD

The databases, Pubmed, Medline, EMBASE, Cochrane and CINAHL were searched using the keywords ('surgical' AND 'checklist') and ( (surgical) AND checklist) AND ( (implementation) OR (utilization) OR (usage) ). Studies were limited to those written in the English language, peer-reviewed, published between January 2000 and December 2012, and including an abstract.

RESULTS

Our search yielded 2242 papers, of which 72 papers were identified for their potential relevance and selected for full text review. Of these, nine papers met the inclusion criteria and were reviewed in detail. Evidence that supports the use of surgical checklists in countries with a large number of protocols already in place is limited. Adequate checklist implementation plays a central role in checklist effectiveness, which in turn is dependent on multiple factors.

CONCLUSION

Although evidence from OECD member countries is non-conclusive, it does suggest that surgical checklists, when effectively implemented, have the potential to be effective at reducing complication and mortality rates following surgery. Within an Australian context, more studies are needed to fully establish the potential effectiveness of surgical checklists and to monitor checklist use compliance in order to ensure greater patient safety.

Checklist de cirurgia segura: análise da segurança e comunicação das equipes de um hospital escola

Este estudo teve como objetivo aplicar o checklist de "cirurgia segura", da Organização Mundial de Saúde, nas especialidades cirúrgicas de um hospital escola, e verificar a opinião das equipes sobre a influência da aplicação do checklist na segurança do processo cirúrgico e da comunicação interpessoal da equipe. Trata-se de um estudo de campo, descritivo, analítico, com abordagem qualitativa, realizado no centro cirúrgico de um hospital-escola. Para a coleta de dados, foi aplicado o checklist num total de 30 cirurgias, conduzido pela pesquisadora, em três etapas, e, a seguir, um componente da equipe cirúrgica foi convidado a participar do estudo, assinando o TCLE e respondendo a questões norteadoras. Para organização e análise dos dados, recorremos ao Método de Análise de Conteúdo de Bardin. Os sujeitos não perceberam mudanças na comunicação interpessoal com o uso do checklist, porém, indicaram que o uso proporcionou mais segurança ao procedimento. Adaptações ao checklist foram sugeridas.

Long-term effects of a perioperative safety checklist from the viewpoint of personnel

BACKGROUND

While positive short-term effects of the use of safety checklists have previously been reported by personnel, it is unclear to which extent these effects are maintained for a long-term period. The aim of the present study was to evaluate perioperative safety standards and the quality of interprofessional cooperation from the viewpoint of the involved personnel for up to 2 years following the introduction of a safety checklist.

METHODS

A survey of 99 co-workers in the departments of anaesthesiology and traumatology was conducted using a 19-point questionnaire concerning perioperative safety-relevant aspects and the quality of interprofessional cooperation before and at 3, 18, and 24 months after the introduction of a safety checklist.

RESULTS

Verification of written consent for surgery (P < 0.01), clear marking of the surgical site (P < 0.01), and time management (P < 0.05) were rated more positively over time by the anaesthesiologists and nurses. Items involving communication were rated less positively after 18 and 24 months than at 3 months. Orthopaedic surgeons rated being better informed about the patients (P < 0.05), the planned operation (P < 0.01), and the assignment of tasks during surgery (P < 0.01) progressively more positively over the time.

CONCLUSIONS

Some positive effects concerning the perioperative organisation and management were rated more positively even 2 years after checklist implementation. However, interprofessional communication and cooperation did not show long-term improvement from staff members' point of view. Probably longer lasting effects for the latter aspects could be achieved by repeated instruction and communication training.

Präventionschecklisten im OP und in der Endoskopie

<b><i>Hintergrund: </i></b>Unerwünschte Ereignisse oder sogar folgenschwere Fehlleistungen entstehen in der Medizin nicht zufällig. Analog zu anderen hochriskanten Arbeitswelten wie der Luftfahrt oder der Kernenergie stellen sie eine Verkettung unglücklicher Umstände bzw. den Zusammenbruch der Multibarrierenstrategie dar. Aus diesem Grund wurden im Laufe der letzten Jahre Checklisten etabliert, die als Teil dieser Sicherheitsbarrieren die Patientensicherheit erhöhen. <b><i>Methode: </i></b>Zur Literaturrecherche wurden die Datenbanken von Medline und PubMed sowie der Internetsuchdienst von Google unter den Suchworten «Checkliste», «Sicherheitscheckliste», zum Teil kombiniert mit «Endoskopie» bzw. «Endoscopy», «Surgical Safety Checklist», «Safety Checklist», «Checklist», «Safety Management» und «WHO-Checklist(e)» abgefragt. Die so identifizierten Publikationen wurden im Folgenden auf die relevanten endoskopischen und chirurgischen Belange hin zusammengestellt und um eigene Erfahrungen aus der Chirurgie und Endoskopie ergänzt. <b><i>Ergebnisse: </i></b>Operationschecklisten sind nachweislich effektive Instrumente zur Erhöhung der Patientensicherheit und Vermeidung von unerwünschten Ereignissen. Dies ist insbesondere auf eine verbesserte Kommunikation bzw. Teaminteraktion zurückzuführen, mit dem Effekt einer dadurch veränderten Sicherheitskultur. Voraussetzung ist ein gutes Checklistendesign und die gelebte Anwendung der Checklisten durch die Leitungsebenen. <b><i>Schlussfolgerungen: </i></b>Operationssaal(OP)-Checklisten verbessern nachhaltig die Sicherheitskultur und erhöhen dadurch die Patientensicherheit. Diese positiven Ergebnisse sollten zunehmend in andere Bereiche der Medizin wie die Endoskopie transferiert werden.

WHO Surgical Safety Checklist in otorhinolaryngology-head and neck surgery: specialty-related aspects of check items

CONCLUSION

The WHO surgical checklist is well suited to otorhinolaryngology-head and neck surgery (ORL-HNS) and the users are satisfied with its content.

OBJECTIVES

Use of the checklist will improve safety in operating rooms (ORs). The checklist has been taken into use in ORL-HNS, and preliminary experiences are promising. However, the checklist must be specific to the specialty in which it is used. The aim of this study was to evaluate the utility of the check items for ORL-HNS operations, with special reference to outpatient surgery.

METHODS

The questionnaire study for the OR personnel was conducted at a tertiary academic hospital. Every item on the WHO checklist was evaluated and responders could provide freehand comments on the subject.

RESULTS

In all, 101 responses were received from OR staff; the response rate was 95.3%. The users were mainly satisfied with the checklist's content for ORL-HNS operations. Mean scores of the importance of check items varied from 4.08 to 4.89 on a five-point scale. The item 'Allergy' had the highest score and 'Team members introduced' the lowest. A need to modify the checklist for in-hospital patients did not emerge. However, a more compact checklist for outpatient surgery carried out under local anaesthesia was suggested.

The effect of the WHO Surgical Safety Checklist on complication rate and communication

BACKGROUND

In 2009, the World Health Organisation issued a worldwide recommendation for the use of its Surgical Safety Checklist in all operative procedures. In this review, we present the available data on the implementation of this checklist and its effect on perioperative morbidity and mortality and on operating-room safety culture. We also survey the experience with the checklist to date and give some recommendations for its practical implementation.

METHODS

We reviewed pertinent original publications retrieved by a selective search in the PubMed and Medline databases on the search term "Surgical Safety Checklist". All papers published before February 2012 were analyzed.

RESULTS

The 20 studies that we analyzed included a single prospective randomized trial concerning the effect of the WHO checklist on safety-related behavior in the operating room. The two surgical outcome studies documented a relative improvement of perioperative mortality by 47% in one study (from 56 in 3733 cases [1.5%] to 32 in 3955 cases [0.8%]) and by 62% in the other (from 31 in 842 cases [3.7%] to 13 in 908 cases [1.4%]), as well as a relative improvement of perioperative morbidity by 36% in one study (from 411 in 3733 cases [11.0%] to 288 in 3,955 cases [7.3%]) and by 37% in the other (from 151 in 842 cases [17.9%] to 102 in 908 cases [11.2%]). Improved interdisciplinary communication was also found. Factors that aided effective use of the checklist included exemplary implementation by team leaders and structured training.

CONCLUSION

These results support the WHO's recommendation to use the Surgical Safety Checklist in all operative procedures. The checklist should be understood not merely as a list of items to be checked off, but as an instrument for the improvement of communication, teamwork, and safety culture in the operating room, and it should be implemented accordingly.