Adherence to the WHO surgical safety checklist: an observational study in a Swiss academic center

Remote Assessment of Real-World Surgical Safety Checklist Performance Using the OR Black Box: A Multi-Institutional Evaluation

BACKGROUND

Large-scale evaluation of surgical safety checklist performance has been limited by the need for direct observation. The operating room (OR) Black Box is a multichannel surgical data capture platform that may allow for the holistic evaluation of checklist performance at scale.

STUDY DESIGN

In this retrospective cohort study, data from 7 North American academic medical centers using the OR Black Box were collected between August 2020 and January 2022. All cases captured during this period were analyzed. Measures of checklist compliance, team engagement, and quality of checklist content review were investigated.

RESULTS

Data from 7,243 surgical procedures were evaluated. A time-out was performed during most surgical procedures (98.4%, n = 7,127), whereas a debrief was performed during 62.3% (n = 4,510) of procedures. The mean percentage of OR staff who paused and participated during the time-out and debrief was 75.5% (SD 25.1%) and 54.6% (SD 36.4%), respectively. A team introduction (performed 42.6% of the time) was associated with more prompts completed (31.3% vs 18.7%, p < 0.001), a higher engagement score (0.90 vs 0.86, p < 0.001), and a higher percentage of team members who ceased other activities (80.3% vs 72%, p < 0.001) during the time-out.

CONCLUSIONS

Remote assessment using OR Black Box data provides useful insight into surgical safety checklist performance. Many items included in the time-out and debrief were not routinely discussed. Completion of a team introduction was associated with improved time-out performance. There is potential to use OR Black Box metrics to improve intraoperative process measures.

Barriers and facilitators associated with the implementation of surgical safety checklists: A qualitative systematic review

AIM

Despite the documented benefits of the World Health Organisation Patient Safety Checklist compliance rates with implementation continue to cause risk to patient safety. This qualitative systematic review aimed to explore the reported factors that impact compliance and implementation processes related to surgical safety checklists in perioperative settings.

DESIGN

A qualitative systematic review.

METHODS

A systematic review using the Joanna Briggs Institute (JBI) approach to synthesize qualitative studies was conducted and reported according to PRISMA guidelines. Electronic databases were expansively searched using keywords and subject headings. Articles were assessed using a pre-selected eligibility criterion. Data extraction and quality appraisal was undertaken for all included studies and a meta-aggregation performed.

DATA SOURCES

The CINAHL, Medline and Scopus databases were searched in August 2022 and the search was repeated in June 2023.

RESULTS

34 studies were included. Following the synthesis of the findings there were multiple interrelating barriers to checklist compliance that impacted implementation. There were more barriers than enablers reported in existing studies. Enablers included effective leadership, education and training, timely use of audit and feedback, local champions, and the option for local modifications to the surgical checklist. Further research should focus on targeted interventions that improve observed compliance rates to optimize patient safety.

CONCLUSION

This qualitative systematic review identified multiple key factors that influenced the uptake of the Surgical Safety Checklist in operating theatres.

IMPLICATIONS FOR THE PROFESSION AND/OR PATIENT CARE

Surgeon participation, hierarchical culture, complacency, and duplication of existing safety processes were identified which impacted the use and completion of the checklist.

Fostering Excellence in Obstetrical Surgery

Introduction

This obstetric surgery review is directed toward the common obstetrical surgeries (caesarean delivery, VBAC/TOLAC, operative vaginal delivery, placenta accreta spectrum) with evidence for quality and safety to allow for obstetrical outcome excellence.

Materials and Methods

This focused scoping review has used a structured process for article identification and inclusion for each of the focused surgeries.

Results

The review results provide an obstetrical surgery (OS) overview for caesarean delivery, vaginal birth after caesarean delivery and/or trial of labor after caesarean delivery, operative vaginal delivery, placenta accreta spectrum; considerations for quality and safety variance due to non-clinical human factors; quality improvement (QI) tools; OS QI implementation cohorts; implementation considering certain barriers and solutions.

Conclusion

Administrative health care systems and obstetrical surgery care providers cannot afford, not to consider and implement, certain evidenced-based "bottom-up/top-down" processes for quality and safety, as the patients will demand the quality and the safety, but the lawyers should not have to enforce it.

Improving surgical safety checklist utilisation at 23 public health facilities in Ethiopia: a collaborative quality improvement project

BACKGROUND

In 2009, the WHO introduced the surgical safety checklist (SSC) as one of the interventions for improving patient safety. The systematic use of structured checklists during surgery has been shown to reduce perioperative morbidity and mortality. However, SSC utilisation has been challenging in low-income and middle-income countries, including Ethiopia. Jhpiego Ethiopia implemented a quality improvement project (QIP) aimed to increase SSC utilisation.

METHODOLOGY

A model for improvement was used to design and implement a collaborative QIP to improve SSC utilisation at 23 public health facilities (13 primary health care facilities, 4 general hospitals and 6 tertiary hospitals) in Ethiopia from October 2020 to September 2021. SSC utilisation was defined as when a patient chart had SSC attached and each part of the checklist was completed. Training of surgical staff on safe surgery packages, monthly clinical mentorship and cluster-based learning platforms were implemented during the study period. We analysed bimonthly chart audit reports from each facility to assess the proportion of surgeries where the SSC was used. Shewhart charts were used to conduct a time-series analysis. Additionally, the Z-test for two sample proportions was used to determine if there is a statistically significant change from the baseline measure with a p<0.05.

RESULT

In the postintervention period, the overall SSC utilisation improved by 39.9 absolute percentage points to 90.3% (p<0.0001) compared with the baseline value of 50.4% early in 2020. A time-series analysis using Shewhart charts showed a shift in the mean performance and signals of special cause variation. The largest improvement was observed in primary health care facilities in which the SSC utilisation improved from 50.8% to 97.9% (p<0.0001).

CONCLUSION

This study demonstrates that onsite clinical capacity building, mentorship and collaborative cluster-based learning platforms can improve SSC utilisation across all levels of facilities performing surgery.

Make a difference: implementation, quality and effectiveness of the WHO Surgical Safety Checklist-a narrative review

Background and Objective

The positive effects of the WHO Surgery Safety Checklist (WHO SSC) have been demonstrated by a large amount of quantitative studies. With this review, the focus changes to the content of qualitative studies on WHO SSC to identify possible research gaps. In this way, gaps in the content of the execution of individual checklists can be closed.

Methods

The two research platforms "Ovid Medline" and "PubMed" formed a solid basis for the literature research. The search was conducted until the 19th of September 2022. The following group terms were used: "checklist", "surgery", "implementation", and "WHO Surgical Safety Checklist". Subsequently, the literature research was limited to studies between 2011 and 2021 in either English or German.

Key Content and Findings

Overall, a positive effect was found in all qualitative studies on WHO SSC with respect to leadership, teamwork, timing and acceptance. Acceptance through effective implementation of the SSC deserves special mention. Several studies highlighted the lack of understanding and training, which led to variation in execution. A large number of studies agree that the WHO SSC is fostering teamwork and improving communication. However, there are also hurdles and barriers in the application that seem to have an influence on the effectiveness.

Conclusions

The exact mechanisms of the advantage and application of the checklist are still poorly understood. Further research in this area is needed for a better understanding of the underlying work culture and consequently improving patient safety.

Implementation of Escape Room as an Educational Strategy to Strengthen the Practice of Safe Surgery

OBJECTIVE

Describe a safe surgery learning experience based on interactive escape room activities to engage and train nursing and physician teams.

DESIGN

This paper is based on the authors' participatory and observational experiences creating the Escape Room activity.

SETTING

Jundiai Regional Hospital, Surgical Department.

PARTICIPANTS

Nurses, nurses assistant/technician and physicians and medical residents who work in the surgical center.

RESULTS

Results identified were promising, which broadens the perspective for further studies using the Escape Room activity in the hospital environment through structured research that can assess its implications for teaching and learning.

CONCLUSION

We see opportunities for using the escape room activity as a teaching tool to implement other learning objectives.

The Nursing Practice Environment and Patients' Satisfaction with Nursing Care in a Hospital Context

Nursing, being a profession in health, aims to improve the quality of the response to patients' demands, which have repercussions on the attitudes, behaviors and performance of nurses.

BACKGROUND

The aim of the study was to evaluate the relationships among the nursing practice environment, nurse-patient interactions and patients' satisfaction with nursing care in a hospital context.

METHODS

The study applied a descriptive analysis. Based on the initial exploration of the data, we decided to perform a simple linear regression of the dimensions of the scales.

RESULTS

The latent variables and interactions between the different dimensions of the three constructs (the nursing practice environment (PES-NWI), nurse-patient interactions (NPIS-22-PT) and patients' satisfaction in the hospital context (SAPSNC-18)) were submitted to confirmatory analysis. The model was statistically significant, with a good fit with the data (χ2/gl = 128.6/41 (0.000); GFI = 0.900; AGFI = 0.831; TLI = 0.910; CFI = 0.907; RMSEA = 0.102).

CONCLUSIONS

The study showed favorable rates of overall satisfaction on the part of patients, such as the nurses' skills in dealing with their illness/health situation, ability to solve problems in a timely manner, responsiveness to patients' needs and technical competence.

WHO Surgical Safety Checklist and Anesthesia Equipment Checklist efficacy in war-affected low-resource settings: a prospective two-arm multicenter study

INTRODUCTION

The Russian invasion of Ukraine has caused huge damage to all medical infrastructure and impairs patient safety. The aim of our study was to assess the impact of implementation of the WHO Surgical Safety Checklist and Anesthesia Equipment Checklist on patient outcomes and adherence to safety standards in low-resource settings, affected by an ongoing war.

MATERIAL AND METHODS

A prospective multicenter study was conducted in 6 large Ukrainian hospitals. The study was conducted in two phases: a control period, lasting five months, followed by a study period, when the two checklists (the WHO Surgical Safety Checklist and Anesthetic Equipment Checklist) were introduced in the designated operating rooms. The primary outcomes were any major complications, including death, during 30 days after surgery.

RESULTS

A total of 2237 surgical procedures were recorded - 1178 in the control group and 1059 in the intervention group. Major postoperative complications occurred in 82 (6.9%) patients in the control group and in 25 (2.4%) in the study group (OR = 0.32 [0.19-0.52], P < 0.001). The effect on the incidence of specific postoperative complications was statistically significant for the "surgical infection" (1.5% vs. 0.1%; OR = 0.31 [0.1-0.8], P = 0.01) and "reoperation" (1.7% vs. 0.5%; OR = 0.32 [0.1-0.8], P = 0.01) cate-gories as well as for the 30-day mortality (1.3% vs. 0.3%; OR = 0.35 [0.1-0.9], P = 0.03). Better adherence to basic WHO surgical safety recommendations was observed for every check mentioned in the WHO Surgical Safety Checklist ( P < 0.05).

CONCLUSIONS

The WHO Surgical Safety Checklist and the Anesthesia Equipment Checklist improve patient outcomes in war-affected low-resource settings.

Factors Causing Variation in World Health Organization Surgical Safety Checklist Effectiveness-A Rapid Scoping Review

INTRODUCTION

This review was conducted to determine what factors might be responsible for prejudicing the outcomes after the implementation of a World Health Organization Surgical Safety Checklist (WHO SSC), grouping them appropriately and proposing strategies that enable the SSC a more helpful and productive tool in the operating room.

METHODS

It was a rapid scoping review conducted as per Preferred Reporting Items for Systematic Review and Meta-analyses extension guidelines for scoping reviews (PRISMA-Scr). Comprehensive search on MEDLINE and Embase was carried out, to include all relevant studies published during last 5 years. Twenty-seven studies were included in analysis. The barriers to SSC implementation were classified into 5 main groups, with further subdivisions in each.

RESULTS

The results of review revealed that there are 5 major barriers to SSC at the following levels: organizational, checklist, individual, technical, and implementation. Each of these major barriers, on further evaluation, was found to have more than one contributing factors. All these factors were analyzed individually.

CONCLUSIONS

This rapid scoping review has consolidated data, which may pave the way for experts to further examine steps that might be taken locally or globally in order that the WHO SSC to successfully achieve all its desired goals.

Factors that enhance compliance with the Surgical Safety Checklist

BACKGROUND

The World Health Organization (WHO) has reported that its Surgical Safety Checklist (SSC) has resulted in significant reductions in morbidity and mortality. Despite its proven success, meaningful compliance with the Surgical Safety Checklist initiative has been low.

AIMS

The authors sought to identify and explore published research on factors that enhance compliance with the SSC within surgical team members.

METHODS

A review of the literature published between January 2017 and January 2021 was undertaken. Six databases were searched, and 1340 studies were screened for eligibility. The 17 studies included were critically appraised using the Crowe Critical Appraisal Tool.

FINDINGS

Three main themes were identified: training and innovations; process adaptations and team leadership.

CONCLUSION

This review of the literature draws attention to the complexities of checklist compliance and identifies the need for training, leadership and adaptation to new safety processes.

A Quality Improvement Initiative Using Peer Audit and Feedback to Improve Compliance with the Surgical Safety Checklist

Background

The Surgical Safety Checklist (SSC) published by the WHO in 2009 is used as standard in surgery worldwide to reduce perioperative patient mortality. However, compliance with the SSC and quality of its application are often not satisfactory. Internal audits and feedbacks seem promising for improving SSC application.

Objective

The purpose of this study is to investigate whether an intervention consisting of peer observation and immediate peer feedback can be implemented with high fidelity and acceptance.

Method

Data were obtained from a national pilot programme that was initiated in Switzerland in 2018 to measure and improve compliance with the SSC using peer audit and feedback. A total of 11 hospitals with 14 sites implemented the full intervention. Each hospital formed an interprofessional project team that should perform at least 30 observations with feedback on SSC application documented in an observation tool developed specifically for this programme. Since the SSCs of the study hospitals differ greatly regarding checklist items, for each of the three SSC sections standard items were defined: four at Sign In, five at Team Time Out and two at Sign Out. Frequency analyses were performed for initiation characteristics, SSC application at item level, feedback characteristics and programme evaluation.

Results

The 11 hospitals documented 715 valid observations, and feedback on SSC application was provided for 79% of the observations. In 61%, all team members stopped their work for the SSC application, and in 71%, the items were read off from the checklist (instead of recalled from memory). On average, 86% of the standard items were read out by the checklist coordinator, whilst the two items at Sign Out were read out only in 60% and 74%. Additional visual checks with another source (e.g. patient wristband) took place in only 41%, and verbal confirmation of the items (by someone else other than the checklist coordinator) was obtained on an average of 76% across all three checklist sections. The surgical teams reacted positively in 64% to the peer feedback.

Conclusion

Both implementation fidelity and acceptability of the intervention were high—the present intervention seems suitable for regular monitoring of the quality of SSC application with internal resources. Peer observation facilitated identifying weaknesses regarding the SSC process and application at item level. Across all hospitals, the Sign Out section in general, visual control for item checks and lack of work interruption of all team members during SSC application showed up as the main areas of improvement.

Compliance with the World Health Organization's surgical safety checklist and related postoperative outcomes: a nationwide survey among 172 health facilities in Ethiopia

Background

Ministry of Health (MOH) of Ethiopia adopted World Health Organization’s evidence-proven surgical safety checklist (SSC) to reduce the occurrence of surgical complications, i.e., death, disability and prolong hospitalization. MOH commissioned this evaluation to learn about SSC completeness and compliance, and its effect on magnitude of surgical complications.

Methods

Health institution-based cross-sectional study with retrospective surgical chart audit was used to evaluate SSC utilization in 172 public and private health facilities in Ethiopia, December 2020–May 2021. A total of 1720 major emergency and elective surgeries in 172 (140 public and 32 private) facilities were recruited for chart review by an experienced team of surgical clinicians. A pre-tested tool was used to abstract data from patient charts and national database. Analyzed descriptive, univariable and bivariable data using Stata version-15 statistical software.

Results

In 172 public and private health facilities across Ethiopia, 1603 of 1720 (93.2%) patient charts were audited; representations of public and private facilities were 81.4% (n = 140) and 18.6% (n = 32), respectively. Of surgeries that utilized SSC (67.6%, 1083 of 1603), the proportion of SSC that were filled completely and correctly were 60.8% (659 of 1083). Surgeries compliant to SSC guide achieved a statistically significant reduction in perioperative mortality (P = 0.002) and anesthesia adverse events (P = 0.005), but not in Surgical Site Infection (P = 0.086). Non-compliant surgeries neither utilized SSC nor completed the SSC correctly, 58.9% (944 of 1603).

Conclusions

Surgeries that adhered to the SSC achieved a statistically significant reduction in perioperative complications, including mortality. Disappointingly, a significant number of surgeries (58.9%) failed to adhere to SSC, a missed opportunity for reducing complications.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13037-022-00329-6.

Classification of intraoperative adverse events in visceral surgery

BACKGROUND

Intraoperative adverse events (iAEs) are frequent in visceral surgery, but severity and related postoperative outcome are poorly investigated. A novel classification of intraoperative adverse events, ClassIntra, includes surgical and anesthesiologic intraoperative adverse events using 5 severity grades and showed a high criterion and construct validity across all surgical disciplines. ClassIntra was studied for reproducibility in a prespecified group of patients undergoing visceral surgery.

METHODS

iAEs were recorded in all patients enrolled in the ClassIntra validation study (NCT03009929). Postoperative complications were assessed daily according to the Clavien-Dindo classification. Results of the visceral group were compared with those of the non-visceral group and the full cohort. The risk-adjusted association between most severe intra and postoperative complications was investigated in a multivariable proportional odds model. Second, risk-adjusted association between ClassIntra grade and Comprehensive Complication Index, and postoperative length of stay was investigated.

RESULTS

In total, 1,270 out of 2,520 patients (50%) underwent visceral surgery. Compared with the nonvisceral group and full cohort, more intraoperative (337/1270 [27%] vs 273/1250 [22%] vs 610/2520 [24%] patients) and postoperative complications (457/1270 [36%] vs 381/1250 [30%] vs 838/2520 [33%] patients) occurred. The risk for a more severe postoperative complication increased with each ClassIntra grade (odds ratio [95% confidence interval] I vs 0 1.10 [0.73 to 1.66], II vs 0 1.69 [1.10 to 2.60], III vs 0 2.31 [1.21 to 4.41], IV vs 0 2.35 [0.69 to 8.06]). Accordingly, CCI and postoperative length of stay increased with each ClassIntra grade in the visceral group, comparable with the nonvisceral and full cohort.

CONCLUSION

Consistent results for the association of intraoperative adverse events and patient outcomes render ClassIntra a valuable instrument in visceral surgery.

Compliance with the surgical safety checklist in Switzerland: an observational multicenter study based on self-reported data

Background

Since publication of the surgical safety checklist by the WHO in 2009, it has been introduced in many hospitals. However, frequency and quality of surgical safety checklist use is often low probably limiting the effectiveness of the checklist in preventing patient harm. The focus of this study was to examine the current state of compliance with the surgical safety checklist in Switzerland and to evaluate how the data relates to international comparative data.

Methods

Between November 2020 and March 2021 twelve hospitals with 15 sites collected for at least 200 surgical interventions each whether the three sections of the surgical safety checklist (Sign In, Team Time Out, Sign Out) have been applied. This data collection was part of a large quality improvement project focusing on measuring and improving compliance with the surgical safety checklist via peer observation and feedback. Descriptive statistics were used to analyze the data; chi-square tests were used to compare sub-samples.

Results

The hospitals collected valid compliance data for 8622 surgical interventions. Mean compliance rate was 91% when distinguishing between the two categories applied (including partially applied) and not applied. In line with previous research, Sign In (93%) and Team Time Out (94%) sections have been applied more frequently than Sign Out (86%). All three surgical safety checklist sections have been applied in 79% of the surgical interventions, no sections in 1%.

Conclusions

The results of this study indicate that the overall application of the surgical safety checklist in Switzerland can be considered high, although the completeness, especially of the Sign Out section, could be improved. At present, it seems difficult to compare compliance rates from different studies as measurement methods and definitions of compliance vary widely. A systematization and homogenization of the methodology within, but also beyond, national borders is desirable for the future.

Intraoperative practices to prevent wrong-level spine surgery: a survey among 105 spine surgeons in the United Kingdom

Background

Current literature suggests that wrong-level spine surgery is relatively common with far-reaching consequences. This study aims to assess the current practices of spinal surgeons across the UK with respect to the techniques implemented for correct level verification.

Methods

To assess the current practices of spinal surgeons across the UK with respect to the techniques implemented for level verification. The authors hypothesise the absence of a standardised technique used across spine surgeons in the UK. Practices amongst respondents will be ascertained via an electronic questionnaire designed to evaluate current practices of spinal surgeons whom are members of the British Association of Spinal Surgeons (BASS). The study data will include key information such as; the level of surgical experience, specific techniques used to perform level checks for each procedure and prior involvement with wrong-level spine surgery. Responses were collected over the period of 1 month with a reminder sent 2 weeks prior to closure of the survey. The data were collated and descriptive analyses performed on multiple-choice question answers and common themes established from free text answers.

Results

A total of 27% (n = 105/383) members responded. The vast majority had greater than 10 years’ experience. Intraoperative practices varied greatly with varying practices present for cervical, thoracic and lumbar level surgery. Only 38% (n = 40) of respondents re-checked the level intra-operatively, prior to instrumentation. Of the respondents 47.5% (n = 29/61) of surgeons had been involved in wrong level spinal surgery.

Conclusion

This study highlights the varying practices amongst spinal surgeons and suggests root cause for wrong-level spine surgery; where the level identified pre-incision was subsequently not the level exposed. We describe a novel safety-check adopted at our institute using concepts and lessons learnt from the WHO Checklist.

Validação de checklist para utilização em cirurgia cardíaca segura

RESUMO Objetivo Construir e validar um instrumento no formato checklist para utilização em cirurgia cardíaca segura. Método Pesquisa metodológica realizada nas seguintes etapas: revisão da literatura; construção dos itens e validação de conteúdo por especialistas em duas etapas, a nível regional com 9 e nacional com 14 juízes. Para análise dos dados, aplicou-se a taxa de concordância por item construído. Resultados A construção da versão 1 resultou em 49 itens, a versão 2 apresentou 46 itens, e a versão final 41 itens distribuídos em Sign in (1 a 27), Time out (28 a 32) e Sign out (33 a 41). Na versão final, todos os itens foram validados com concordância superior a 80%. Conclusão O checklist foi construído e validado quanto ao conteúdo, composto por 41 itens,e poderá ser utilizado na área de cirurgia cardíaca para a implementação de assistência segura aos pacientes submetidos a esses procedimentos.

Checklist validation for use in safe heart surgery

ABSTRACT Objective Build and validate an instrument in checklist format for use in safe cardiac surgery. Method Methodological research carried out in the following stages: literature review; national construction of items and content validation by experts in two stages, at regional level 9 and with 41 judges. For data analysis, the agreement rate per constructed item was determined. Results The construction of version 1 resulted in 49 items, version 2 presented 46 items, and the final version 41 items distributed in Sign in (1 to 27), Time out (28 to 32) and Sign out (33 to 41). All items obtained agreement greater than 80%, considering validated. Conclusion The checklist was built and validated in terms of content, consisting of 41 items, and can be used in the area of cardiac surgery for the implementation of safe care for patients undergoing these procedures.

Surgical safety checklist audits may be misleading! Improving the implementation and adherence of the surgical safety checklist: a quality improvement project

Despite good quality evidence for benefits with its use, challenges have been encountered in the correct and consistent implementation of the surgical safety checklist (SSC). Previous studies of the SSC have reported a discrepancy between what is documented and what is observed in real time. A baseline observational audit at our institution demonstrated compliance of only 3.5% despite a documented compliance of 100%. This project used quality improvement principles of identifying the problem and designing strategies to improve staff compliance with the SSC. These included changing the SSC from paper-based to a reusable laminated form, a broad multidisciplinary education and marketing campaign, targeted coaching and modifying the implementation in response to ongoing staff feedback. Five direct observational audits were undertaken over four Plan–Do–Study–Act cycles to capture real-time information on staff compliance. Two staff surveys were also undertaken. Compliance with the SSC improved from 3.5% to 63% during this study. Staff reported they felt the new process improved patient safety and that the new SSC was easily incorporated into their workflow. Improving compliance with the SSC requires deep engagement with and cooperation of surgical, anaesthesia and nursing teams and understanding of their work practices and culture. The prospective observational audit highlighted an initial 3.5% compliance rate compared with 100% based on an audit of the patient notes. Relying solely on a retrospective paper-based model can lead to hospitals being unaware of significant safety and quality issues. While in-person prospective observations are more time-consuming and resource-consuming than retrospective audits, this study highlights their potential utility to gain a clear picture of actual events. The significant variation between documented and observed data may have considerable implications for other retrospective studies which rely on human-entered data for their results.

A Systematic Review of Interventions Used to Enhance Implementation of and Compliance With the World Health Organization Surgical Safety Checklist in Adult Surgery

The focus of this systematic review is to identify and synthesize the evidence for effectiveness of interventions to increase compliance with the World Health Organization Surgical Safety Checklist (SSC) for adult surgery. We searched a variety of databases and identified 24 peer-reviewed articles of either a quantitative (n = 17), qualitative (n = 4), or mixed-methods design (n = 3) published in English from January 1, 2008, to July 8, 2020. Interventions included modifying the ways of delivering the SSC, integrating or tailoring the SSC to local context or existing practice, promoting clinician awareness and engagement, and managing policies. Despite a lack of common outcome measures, all quantitative and mixed-methods study results showed a significant positive effect on SSC compliance. A few researchers reported nonsignificant or negative changes in certain aspects with the interventions. Additional research is needed to address SSC compliance measures globally and outcomes in developing countries.

Improving the WHO Surgical Safety Checklist sign-out

BACKGROUND

The WHO Surgical Safety Checklist has been shown to reduce perioperative morbidity and mortality worldwide. There is evidence to suggest that sign-out is the most poorly performed phase of the checklist as it coincides with a period of high workload for team members. This study aimed to see whether modification of this process might result in greater compliance.

METHODS

A controlled longitudinal (before and after) study was performed to evaluate the effect of a modified checklist sign-out on compliance in a single surgical department. Checklist quality was evaluated by measurement of checklist completion, active participation, and team member presence. Workload assessment was performed to identify the optimal moment for the sign-out process. The sign-out process was modified through an iterative multidisciplinary approach, informed by results from the workload assessment. Feedback was obtained through staff surveys.

RESULTS

A total of 185 operations were used, with an intervention group in vascular surgery and a control group in orthopaedics. The optimal timing for sign-out was identified as after final wound closure. The modified sign-out process improved active participation of team members (21 of 34 versus 31 of 34; P = 0.010). In the control group, complete compliance improved (48 of 76 versus 30 of 41; P = 0.041). However, active participation decreased (53 of 76 versus 19 of 41; P = 0.022). No differences were noted between groups in team member presence. Eighteen of 21 staff questioned viewed the modifications positively.

CONCLUSION

The optimal sign-out timing was identified as immediately after final wound closure prior to undraping the patient.

How Much and What Local Adaptation Is Acceptable? A Comparison of 24 Surgical Safety Checklists in Switzerland

OBJECTIVES

In 2009, the World Health Organization (WHO) published the WHO Surgical Safety Checklist, and 3 years later, the Swiss Patient Safety Foundation adapted it for Switzerland. Several meta-analyses and systematic reviews showed ambiguous results on the effectiveness of surgical checklists. Most of them assume that the study checklists are almost identical, but in fact they are quite heterogeneous due to adaptations to local settings. This study aims to investigate the extent to which the checklists currently used in Switzerland differ and to discuss the consequences of local adaptations.

METHODS

For the analysis, 24 checklists used in 18 Swiss hospitals are analyzed. First, general checklist characteristics are examined. Second, the checklist items are compared with the checklist items of the WHO and the Swiss Patient Safety Foundation.

RESULTS

The checklists contain a median of 34.5 items (range, 15-76). Compared with the checklists of WHO and Patient Safety Switzerland, which contain 12 and 21 process checks and 10 and 9 conversation prompts, respectively, the study checklists contain a median of 15.5 process checks (range, 3-25) and a median of 4 conversation prompts (range, 0-10).

CONCLUSIONS

There are major differences between the study checklists and the reference checklists that raise doubts about the comparability of checklists. More resources must be invested in proper checklist adaptions and better guidance on how to adapt safety tools such as the surgical safety checklist needed to local conditions. In any case, details of the checklists used need to be clearly described in studies on checklist effectiveness.

Incorporating patient safety into early undergraduate medical education: teaching medical students to perform surgical time outs during anatomy

OBJECTIVES

To introduce surgical safety checklists and time outs to future physicians through early incorporation of time outs in the first year gross anatomy course.

SETTING

The Wayne State University School of Medicine Anatomy Lab.

PARTICIPANTS

Approximately 300 first year medical students per year participated in the intervention.

INTERVENTIONS

An educational presentation on medical errors focusing on surgical errors was developed. Students in 2017-2018 viewed the presentation and completed two time outs, one with the first anatomy dissection and a second with the last dissection. Preintervention and postintervention surveys were completed and results compared. Students completed a second postintervention survey after the second time out. Students in 2018-2019 were asked to complete the time outs before every dissection. Time out procedure sheets were collected to determine completion rates. The intervention was further modified for academic year 2019-2020 and time out sheets were again collected.

OUTCOME MEASURES

Four domains of learning were surveyed: (1) major components and goals/limitations of universal protocol, (2) medical error lexicon, (3) components of a time out, and (4) confidence in completing time out checklists.

RESULTS

Postintervention surveys demonstrated significant improvement in each domain. Students found time outs easy to complete and developed confidence in performing time outs. Following a successful pilot, time outs were incorporated into every dissection. Students continued to perform this procedure despite absence of adverse consequences for not doing so.

CONCLUSION

Students found the time outs easy to complete and developed the confidence and ability to perform a surgical time out early in their medical education. The new skills, knowledge and attitudes that these medical students have developed will hopefully improve the care they provide to patients, thereby advancing the practice of quality improvement and patient safety in the clinical setting.

A Mixed-Methods Study to Explore the Impact of Hospital Accreditation

There are several hospital accreditors globally but there is limited understanding of how accreditation impacts on hospital performance and the health system objectives. The objective of the study were to explore the impact of hospital accreditation and inform policy decision-making. We adopted a mixed-methods approach to include an online survey and 3 focus groups. We report 27 of 36 private hospitals who responded to the survey. Key reasons for accreditation were to improve quality (n = 23), implement evidence-based practice (n = 17), continuity of accreditation (n = 15), and popularity (n = 11). Reported improvements include quality of care (27), patient care (26), organizational processes (21), and patient satisfaction (19) among others. Average stakeholder satisfaction rate was 74%. Participants from the 3 focus group discussions felt that staff hours and stress levels were high during the accreditation process, and some standards were useful while others were deemed non-essential. There was support for a local accreditation body with an emphasis on best practice. The findings from the study suggest accreditation to have an impact on structure and process measures, but the gains in key areas were short-lived. There is a need to strengthen governance and develop performance measures to evidence outcome improvement, assure alignment with regulation and the health system objectives.

Use of a surgical safety checklist after implementation in an academic veterinary hospital

OBJECTIVE

To determine the use and barriers to uptake of a surgical safety checklist (SSC) after implementation in a veterinary teaching hospital.

STUDY DESIGN

Voluntary online survey and retrospective study.

SAMPLE POPULATION

All personnel actively involved in the Ontario Veterinary College Health Sciences Centre small animal surgery service between October 2, 2018 and June 28, 2019.

METHODS

Surgical case logs and electronically initiated SSC were reviewed to calculate checklist use. The sample population was surveyed to identify factors and barriers associated with use of the SSC. Participants were allowed 1 month to respond, and five reminder emails were sent.

RESULTS

Forth-one of 50 (82%) participants completed the survey. The SSC was used in 374 of 784 (47.7%) surgeries. Use rates declined over sequential three-month intervals (P < .0001). Twenty-six of 41 (63%) respondents overestimated checklist use. Staff attitudes were largely supportive of the SSC, with 29 of 41 respondents suggesting mandatory application. Forgetfulness, hierarchal concerns, timing issues, perceived delays in care, lack of clarity regarding roles, and inadequate training were identified as obstacles to use of the SSC.

CONCLUSION

The SCC tested in this study was used in approximately half of the surgical procedures performed after its implementation. Hospital personnel were supportive of the SSC; forgetting to use the SSC was the most common barrier identified by respondents (24/41 [59%]).

CLINICAL SIGNIFICANCE

The SSC implementation experience and user feedback described here should be taken into consideration to improve design and implementation of future SSC.

Development of an Electronic Medical Record for Extracorporeal Membrane Oxygenation and Its Role in a Multidisciplinary Team

As the extracorporeal membrane oxygenation (ECMO) program at our institution has grown and our staffing model has evolved into a multidisciplinary team, our method of ECMO charting has also evolved, using an electronic medical record (EMR) with electronic checklists, progress notes, and remote access. Using our EPIC charting platform, version 1 of our EMR was implemented in 2015. It has been revised three times, and remote access deemed necessary to properly support our staff and patients. Our current, yet still evolving, remotely accessible, ECMO EMR incorporates hourly charting and protocol-based checklists for procedures such as initiation of support, shift handoffs, circuit checks, and patient transport. Perfusionists are required to fill out thrice daily progress notes, notes for bedside/operating room procedures, and patient transport. We present a format for centers looking to implement a comprehensive EMR for ECMO patients. An expanding ECMO program required a change to our staffing model, and an EMR with electronic checklists and remote access facilitated the transition to a multidisciplinary team. Protocol-based checklists ensure consistency during procedures, transports, and shift changes. The remote access and required progress notes create a safer team approach and keep our perfusionists engaged when specialists are sitting ECMO.

The negative impact of wearing personal protective equipment on communication during coronavirus disease 2019

Background

Coronavirus disease 2019 personal protective equipment has been reported to affect communication in healthcare settings. This study sought to identify those challenges experimentally.

Method

Bamford–Kowal–Bench speech discrimination in noise performance of healthcare workers was tested under simulated background noise conditions from a variety of hospital environments. Candidates were assessed for ability to interpret speech with and without personal protective equipment, with both normal speech and raised voice.

Results

There was a significant difference in speech discrimination scores between normal and personal protective equipment wearing subjects in operating theatre simulated background noise levels (70 dB).

Conclusion

Wearing personal protective equipment can impact communication in healthcare environments. Efforts should be made to remind staff about this burden and to seek alternative communication paradigms, particularly in operating theatre environments.