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

The Creation of a Pediatric Surgical Checklist for Adult Providers

Purpose

To address the need for a pediatric surgical checklist for adult providers.

Background

Pediatric surgery is unique due to the specific needs and many tasks that are employed in the care of adults require accommodations for children. There are some resources for adult surgeons to perform safe pediatric surgery and to assist such surgeons in pediatric emergencies, we created a straightforward checklist based on current literature. We propose a surgical checklist as the value of surgical checklists has been validated through research in a variety of applications.

Methods

Literature review on PubMed to gather information on current resources for pediatric surgery, all papers on surgical checklists describing their outcomes as of October 2022 were included to prevent a biased overview of the existing literature. Interviews with multiple pediatric surgeons were conducted for the creation of a checklist that is relevant to the field and has limited bias.

Results

42 papers with 8529061 total participants were included. The positive impact of checklists was highlighted throughout the literature in terms of outcomes, financial cost and team relationship. Certain care checkpoints emerged as vital checklist items: antibiotic administration, anesthetic considerations, intraoperative hemodynamics and postoperative resuscitation. The result was the creation of a checklist that is not substitutive for existing WHO surgery checklists but additive for adult surgeons who must operate on children in emergencies.

Conclusion

The outcomes measured throughout the literature are varied and thus provide both a nuanced view of a variety of factors that must be taken into account and are limited in the amount of evidence for each outcome. We hope to implement the checklist developed to create a standard of care for pediatric surgery performed in low resource settings by adult surgeons and further evaluate its impact on emergency pediatric surgery outcomes.

Funding

Fulbright Fogarty Fellowship, GHES NIH FIC D43 TW010540.

Surgical safety checklists in UK veterinary practice: Current implementation and attitudes towards their use

BACKGROUND

Surgical safety checklist (SSC) use benefits veterinary patients, but endorsement and implementation are essential for these benefits to be observed.

METHODS

A cross-sectional survey assessed UK veterinary professionals' attitudes towards and usage of SSCs and identified factors associated with poorer attitude or failure to use SSCs.

RESULTS

Of 513 respondents, 70% used SSCs. Of these, 87.1% used SSCs for every surgical procedure, 19.1% adapted SSCs for different procedures and 61.1% had a standard operating procedure detailing how to use SSCs. Attitudes towards SSC use were favourable, with increased positive attitude associated with employing at least one registered veterinary nurse with a post-qualifying qualification (p < 0.001), current SSC use (p < 0.001), undertaking self-directed reading (p = 0.033) or completing SSC-relevant post-qualification continuing professional development (p = 0.005). Factors associated with veterinary practices not using SSCs included Practice Standards Scheme (PSS) non-membership (odds ratio [OR] 2.0, 1.1-3.4), no RCVS hospital status (OR 1.9, 1.1-3.5) or being a mixed first-opinion veterinary practice (OR 2.4, 1.2-5.0).

LIMITATIONS

Study limitations include sampling methodology and non-validated attitudinal scale usage.

CONCLUSION

Most respondents used SSCs. Familiarity, education and the RCVS PSS were associated with improved uptake and attitudes, but mixed practice was associated with reduced usage.

Knowledge and attitudes towards surgical safety checklists: a survey of veterinary professionals

OBJECTIVE

To determine the knowledge and use of safe surgical checklists (SSCs) and surgical safety practices (SSPs) in different sectors of veterinary medicine.

SAMPLE

1,235 small animal veterinarians who perform surgery in the United States and Canada.

PROCEDURES

An online survey was distributed to veterinarians through social media platforms, specialty listservs, and the Veterinary Information Network. Respondents provided information regarding their role, practice type, as well as knowledge, attitudes, and use of SSCs. Respondents also provided information about performance of SSPs including team introductions; confirmation of antibiotic prophylaxis, patient identity, procedure to be performed; and confirmation of completion of all procedures.

RESULTS

A greater proportion of Diplomates of the American College of Veterinary Surgeons (49/77 [64%]) reported using an SSC than other veterinarians (257/1157 [22%]; P < .0001). A greater proportion of veterinarians working in university and multispecialty hospitals reported using a SSC (71/142 [50%]) than in other practice settings (235/1092 [22%]; P < .0001). Use of a SSC correlated with consistent performance of surgical safety practices listed above (P < .0001). Primary care veterinarians commonly reported not using a SSC because they did not know about them (359/590 [61%]). Of the 507 respondents who had ever used a SSC, 333 (66%) believed the checklist had prevented an error or complication.

CLINICAL RELEVANCE

Despite widespread knowledge and adoption of SSC use in human medicine, knowledge and use of SSCs is lacking in primary care veterinary practice. Checklist use has previously been shown to decrease post operative complications and in this study was correlated with increased use of SSPs that decreased complications.

Checklists in Healthcare: Operational Improvement of Standards using Safety Engineering - Project CHOISSE - A framework for evaluating the effects of checklists on surgical team culture

The CHOISSE multi-stage framework for evaluating the effects of electronic checklist applications (e-checklists) on surgical team members' perception of their roles, performance, communication, and understanding of checklists is introduced via a pilot study. A prospective interventional cohort study design was piloted to assess the effectiveness of the framework and the sociotechnical effects of the e-checklist. A Delphi process was used to design the stages of the framework based on literature and expert consensus. The CHOISSE framework was applied to guide the implementation and evaluation of e-checklists on team culture for ten pilot teams across the US over a 24-week period. The pilot results revealed more engagement by surgeons than non-surgeons, and significant increases in surgeons' perception of communication and engagement during surgery with a small sample. Mixed methods analysis of the data and lessons learned were used to identify iterative improvements to the CHOISSE framework and to inform future studies.

Barriers and enablers to utilisation of the WHO surgical safety checklist at the university teaching hospital in Lusaka, Zambia: a qualitative study

Background

Surgical perioperative deaths and major complications are important contributors to preventable morbidity, globally and in sub-Saharan Africa. The surgical safety checklist (SSC) was developed by WHO to reduce surgical deaths and complications, by utilising a team approach and a series of steps to ensure the safe transit of a patient through the surgical operation. This study explored barriers and enablers to the utilisation of the Checklist at the University Teaching Hospital (UTH) in Lusaka, Zambia.

Methods

A qualitative case study was conducted involving members of surgical teams (doctors, anaesthesia providers, nurses and support staff) from the UTH surgical departments. Purposive sampling was used and 16 in-depth interviews were conducted between December 2018 and March 2019. Data were transcribed, organised and analysed using thematic analysis.

Results

Analysis revealed variability in implementation of the SSC by surgical teams, which stemmed from lack of senior surgeon ownership of the initiative, when the SSC was introduced at UTH 5 years earlier. Low utilisation was also linked to factors such as: negative attitudes towards it, the hierarchical structure of surgical teams, lack of support for the SSC among senior surgeons and poor teamwork. Further determinants included: lack of training opportunities, lack of leadership and erratic availability of resources. Interviewees proposed the following strategies for improving SSC utilisation: periodic training, refresher courses, monitoring of use, local adaptation, mobilising the support of senior surgeons and improvement in functionality of the surgical teams.

Conclusion

The SSC has the potential to benefit patients; however, its utilisation at the UTH has been patchy, at best. Its full benefits will only be achieved if senior surgeons are committed and managers allocate resources to its implementation. The study points more broadly to the factors that influence or obstruct the introduction and effective implementation of new quality of care initiatives.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-08257-y.

Compliance and Attitudes of Critical Care Transport Providers Regarding a Prehospital Rapid Sequence Intubation Checklist

Human factors engineering innovations, such as checklists, have been adopted in various acute care settings to improve safety with reasonable compliance and acceptance. In the air medical industry, checklists have been implemented by different teams for critical clinical procedures such as rapid sequence intubation. However, compliance and attitudes toward these human factors engineering innovations in the critical care transport setting are not well described. In this institutional review board-exempt, retrospective review of checklist usage, we assessed rapid sequence intubation checklist compliance and surveyed providers with 5 questions based on Rogers' theory of diffusion of innovation to examine why or why not there was compliance. Our results indicated that compliance with checklist implementation was excellent. The survey questions were consistent with process improvement factors that enhance the spread and acceptance of innovation.

Surgical Teams' Attitudes About Surgical Safety and the Surgical Safety Checklist at 10 Years: A Multinational Survey

To assess health care professionals' attitudes on the Surgical Safety Checklist ("the Checklist") in resource-rich health systems and provide insights on strategies for optimizing Checklist use.

Background

In use for over a decade, the Checklist is a safety instrument aimed at improving operating room communication, teamwork, and evidence-based safety practices.

Methods

An online survey was sent to surgeons, nurses, and anesthesiologists in 5 high-income countries (Canada, the United States, the United Kingdom, Australia, and New Zealand). Survey results were analyzed using SPSS.

Results

A total of 2032 health care professionals completed the survey. Of these respondents, 47.6% were nurses, 70.5% were women, 65.1% were from the United States, and 50.0% had 20 years of experience or more in their role. Most respondents felt the Checklist positively impacted patient safety (70.9%), team communication (73.1%), and teamwork (58.9%). Only 50.3% of respondents were satisfied their team's use of the Checklist, and only 47.5% reported team members stopping to fully participate in the process. More nurses lacked confidence regarding their role in the Checklist process than surgeons and anesthesiologists combined (8.9% vs 4.3%). Fewer surgeons and anesthesiologists than nurses felt they received adequate training on the Checklist's use (57.8% vs 76.7%).

Conclusions

While most respondents perceive the Checklist as enhancing patient safety, not all surgical team members are actively engaging with its use. To enhance buy-in and meaningful use of the Checklist, health systems should provide more training on the Checklist with respect to its purpose and strengthening teamwork.

Pre-induction checklists and discomfort in patients. An observational study

BACKGROUND

Since the WHO release of the Safe Surgery Saves Lives Program in 2008, peri-operative checklists minimise errors and improve patient safety worldwide. Anaesthesia professionals are often reluctant to use these checklists in front of patients because they fear causing patients' discomfort before anaesthesia and surgery.

OBJECTIVE

To assess and compare the subjective level of patient discomfort caused by the use of pre-induction checklists with the patient discomfort estimated by anaesthesia providers.

DESIGN

Prospective observational study.

SETTING

The current single-centre trial included 110 anaesthesia providers and 125 nonpremedicated ear, nose and throat or maxillofacial surgery patients in Switzerland from June to August 2016. Inclusion criterion: signed general research consent.

EXCLUSION CRITERIA

received premedication, less than 18 years old, day-care patients, dementia or other mental illnesses.

INTERVENTIONS

Anaesthesia healthcare providers and patients before surgery and on the first postoperative day were asked to rate three statements: MAIN OUTCOME MEASURES: All statements were rated on a 100-mm visual analogue scale, where 0 meant no agreement and 100 meant total agreement.

RESULTS

Patients overwhelmingly agreed that anaesthesia providers should use checklists in front of them. Anaesthesia providers rated the patient discomfort much higher than actually perceived by patients. Both, patients and anaesthesia providers rated the possibility of reducing the risk of errors high.

CONCLUSION

Patients experience far less discomfort observing the use of pre-induction checklists than anaesthesia providers expect. Patients value the potential safety benefit significantly higher than anaesthesia providers. These results further support the implementation of peri-operative checklists in the operating room environment.

TRIAL REGISTRATION

The current observational study had no intervention, therefore, was not registered.

Global Survey of Perceptions of the Surgical Safety Checklist Among Medical Students, Trainees, and Early Career Providers

BACKGROUND

The Surgical Safety Checklist (SSC) has been shown to reduce perioperative complications across global health systems. We sought to assess perceptions of the SSC and suggestions for its improvement among medical students, trainees, and early career providers.

METHODS

From July to September 2019, a survey assessing perceptions of the SSC was disseminated through InciSioN, the International Student Surgical Network comprising medical students, trainees, and early career providers pursuing surgery. Individuals with ≥2 years of independent practice after training were excluded. Respondents were categorized according to any clinical versus solely non-clinical SSC exposure. Logistic regression was used to evaluate associations between clinical/non-clinical exposure and promoting future use of the SSC, adjusting for potential confounders/mediators: training level, human development index, and first perceptions of the SSC. Thematic analysis was conducted on suggestions for SSC improvement.

RESULTS

Respondent participation rate was 24%. Three hundred and eighteen respondents were included in final analyses; 215 (67%) reported clinical exposure and 190 (60%) were promoters of future SSC use. Clinical exposure was associated with greater odds of promoting future SSC use (aOR 1.81 95% CI [1.03-3.19], p = 0.039). A greater proportion of promoters reported "Improved Operating Room Communication" as a goal of the SSC (0.21 95% CI [0.15-0.27]-vs.-0.12 [0.06-0.17], p = 0.031), while non-promoters reported the SSC goals were "Not Well Understood" (0.08 95% CI [0.03-0.12]-vs.-0.03 [0.01-0.05], p = 0.032). Suggestions for SSC improvement emphasized context-specific adaptability and earlier formal training.

CONCLUSIONS

Clinical exposure to the SSC was associated with promoting its future use. Earlier formal clinical training may improve perceptions and future use among medical students, trainees, and early career providers.

How does the WHO Surgical Safety Checklist fit with existing perioperative risk management strategies? An ethnographic study across surgical specialties

BACKGROUND

The World Health Organization (WHO) Surgical Safety Checklist (SSC) has demonstrated beneficial impacts on a range of patient- and team outcomes, though variation in SSC implementation and staff's perception of it remain challenging. Precisely how frontline personnel integrate the SSC with pre-existing perioperative clinical risk management remains underexplored - yet likely an impactful factor on how SSC is being used and its potential to improve clinical safety. This study aimed to explore how members of the multidisciplinary perioperative team integrate the SSC within their risk management strategies.

METHODS

An ethnographic case study including observations (40 h) in operating theatres and in-depth interviews of 17 perioperative team members was carried out at two hospitals in 2016. Data were analysed using content analysis.

RESULTS

We identified three themes reflecting the integration of the SSC in daily surgical practice: 1) Perceived usefullness; implying an intuitive advantage assessment of the SSC's practical utility in relation to relevant work; 2) Modification of implementation; reflecting performance variability of SSC on confirmation of items due to precence of team members; barriers of performance; and definition of SSC as performance indicator, and 3) Communication outside of the checklist; including formal- and informal micro-team formations where detailed, specific risk communication unfolded.

CONCLUSION

When the SSC is not integrated within existing risk management strategies, but perceived as an "add on", its fidelity is compromised, hence limiting its potential clinical effectiveness. Implementation strategies for the SSC should thus integrate it as a risk-management tool and include it as part of risk-management education and training. This can improve team learning around risk comunication, foster mutual understanding of safety perspectives and enhance SSC implementation.

Effects of a Perioperative Safety Checklist on Postoperative Complications Following Surgery for Gastric Cancer: A Single-Center Preliminary Study

Objective. A Perioperative Safety Checklist (PSC) for gastric cancer (GC) was established to evaluate the effects of PSC on the clinical outcomes of GC. Methods. This single-center preliminary observational study conducted at a tertiary referral hospital included patients with GC who underwent surgery from January 1, 2016, to June 30, 2016, treated without PSC (allocated to the control group) and those who underwent surgery between January 1, 2017, and June 30, 2017, managed according to the PSC designated as the PSCGC (Perioperative Safety Checklist for Gastric Cancer) group. Results. Overall, 1072 cases were enrolled, 556 cases in PSCGC group and 526 cases in control group. After matching, there were 474 patients in each group. PSC intervention led to significant reductions of the incidence of postoperative intestinal fistula formation ( P = .034), the incidence of unplanned secondary surgery ( P = 0.039), and the total hospitalization expenses ( P < .001). Total completion rate of all 14 checklists items was 79.1%. Intraoperative blood loss in the complete and partial implementation groups was significantly lower than the complete nonimplementation group ( P = .002), whereas hospitalization cost showed an opposite trend, which was significantly higher in the incomplete nonimplementation group ( P = .015). Conclusion. PSC implementation was associated with a decreased incidence of gastrointestinal fistula formation, unplanned secondary surgery, and hospitalization cost in patients with GC. However, it had no effect on the in-hospital mortality, the incidence of postoperative complications during hospitalization (ie, incision complications and lung infections), unplanned secondary admission, and the duration of postoperative hospital stay.

Gynecology healthcare professionals towards safety procedures in operation rooms aiming to enhanced quality of medical services in Greece

PURPOSE

The purpose of this paper is to investigate the attitudes of healthcare professionals in Greece toward safety practices in gynecological Operation Rooms (ORs).

DESIGN/METHODOLOGY/APPROACH

An anonymous self-administered questionnaire was distributed to surgical personnel asking for opinions on safety practices during vaginal deliveries (VDs) and gynecological operations (e.g. sponge/suture counting, counting documentation, etc.). The study took place in Hippokration Hospital of Thessaloniki including 227 participants. The team assessed and statistically analyzed the questionnaires.

FINDINGS

Attitude toward surgical counts and counting documentation, awareness of existence and/or implementation in their workplace of other surgical safety objectives (e.g. WHO safety control list) was assessed. In total, 85.2 percent considered that surgical counting after VDs is essential and 84.9 percent admitted doing so, while far less reported counting documentation as a common practice in their workplace and admitted doing so themselves (50.5/63.3 percent). Furthermore, while 86.5 percent considered a documented protocol as necessary, only 53.9 percent admitted its implementation in their workplace. Remarkably, 53.1 percent were unaware of the WHO safety control list for gynecological surgeries.

ORIGINALITY/VALUE

Most Greek healthcare professionals are well aware of the significance of surgical counting and counting documentation in gynecology ORs. However, specific tasks and assignments are unclear to them. Greek healthcare professionals consider surgical safety measures as important but there is a critical gap in knowledge when it comes to responsibilities and standardized processes during implementation. More effective implementation and increased personnel awareness of the surgical safety protocols and international guidelines are necessary for enhanced quality of surgical safety in Greece.

Patient safety awareness among 309 surgeons in Enugu, Nigeria: a cross-sectional survey

Background

Adverse healthcare events are major public health problem with the heaviest burden in the low and middle-income countries. Patient safety awareness among healthcare professionals is known to impact this outcome; thus we set out to appraise the patient safety awareness among surgeons in Enugu, Nigeria.

Methods

A multi-institutional cross-sectional survey was carried out among surgeons in Enugu, Nigeria and data obtained were analyzed using the statistical package for scientific solutions (SPSS) version 20 software.

Results

A total of 309 surgeons were surveyed. Majority of the surgeons (51.9%) had poor perception of patient safety issues. One hundred and twenty respondents (38.8%) have awareness of any institutional protocol for preventing wrong-site surgery while only 35 respondents (11.3%) regularly practiced an institutional protocol for preventing wrong-site surgery. The professional status of the surgeons and years in service showed significant association with perception of patient safety issues.

Conclusion

The patient safety awareness and practice among the surgeons in Enugu, Nigeria is apparently low and this was found to be influenced by the professional status and years in service of the surgeon.

Safety and Communication in the Operating Room: A Safety Questionnaire After the Implementation of a Blood-Borne Pathogen Exposure Checkpoint in the Surgical Safety Checklist Preprocedure Time-Out

INTRODUCTION

The Surgical Safety Checklist (SSC) decreases patient morbidity and mortality and improves operating room (OR) communication. However, the SSC does not currently include any discussion on employee safety. One institution has implemented a blood-borne pathogen exposure (BBPE) checkpoint in the SSC in order to improve employee safety and to further improve communication. The aim of this study was to determine if the implementation of a BBPE checkpoint improved caregiver safety and communication in the OR.

METHODS

This was a multidisciplinary prospective survey study in which an anonymous questionnaire was distributed to all OR personnel who handle sharps. Survey responses were analyzed for demographics and BBPE safety attitudes. The frequency of reported BBPE incidents collected from quality improvement data 12 months before and after the implementation of the BBPE checkpoint were reviewed.

RESULTS

Caregivers feel safer in the OR with the BBPE checkpoint (p < 0.001). Communication was improved. Compliance in trauma surgeries was less than elective. Reported BBPE incidents were significantly decreased based on quality improvement data (p = 0.045).

CONCLUSION

The BBPE checkpoint was implemented in the SSC at one institution in order to emphasize employee safety and improve communication. The results shed light on the attitudes of OR personnel by suggesting an improvement in safety and communication. In addition, there has been decrease of reported BBPE incidents among OR personnel. Universal implementation of a BBPE checkpoint could improve provider safety and communication in all ORs.

Qualitative outcomes of Clean Cut: implementation lessons from reducing surgical infections in Ethiopia

BACKGROUND

Clean Cut is a six month, multi-modal, adaptive intervention aimed at reducing surgical infections through improving six critical perioperative processes: 1) handwashing/skin preparation, 2) surgical gown/drape integrity, 3) antibiotic administration, 4) instrument sterility, 5) gauze counts, and 6) WHO Surgical Safety Checklist use. The aim of this study was to elucidate themes across Clean Cut implementation sites in Ethiopia to improve implementation at future hospitals.

METHODS

We conducted semi-structured interviews of 20 clinicians involved in Clean Cut at four hospitals. Participation was limited to Clean Cut team members and included surgeons, anesthetists, operating room (OR) nurses, ward nurses, OR managers, quality improvement personnel, and hospital administrators. Audio recordings were transcribed and coded using qualitative software. A codebook was inductively and iteratively derived between two researchers, tested for inter-rater reliability, and applied to all transcripts. We conducted thematic analysis to derive our final qualitative results.

RESULTS

The interviews revealed barriers and facilitators to the implementation of Clean Cut, as well as strategies for future implementation sites. Key barriers included material resource limitations, feelings of job burden, existing gaps in infection prevention education, and communication errors during data collection. Common facilitators included strong hospital leadership support, commitment to improved patient outcomes, and organized Clean Cut training sessions. Future strategies include resource assessments, creating a sense of responsibility among staff, targeted training sessions, and incorporating new standards into daily routine.

CONCLUSIONS

The findings of this study highlight the importance of engaging hospital leadership, providers and staff in quality improvement programs, and understanding their work contexts. The identified barriers and facilitators will inform future initiatives in the field of perioperative infection prevention.

Surgical safety checklist training: a national study of undergraduate medical and nursing student teaching, understanding and influencing factors

INTRODUCTION

Use of the WHO surgical safety checklist is consistently recognised to reduce harm caused by human error during the perioperative period. Inconsistent engagement is considered to contribute to persistence of surgical Never Events in the National Health Service. Most medical and nursing graduates will join teams responsible for the perioperative care of patients, therefore appropriate undergraduate surgical safety training is needed.

AIMS

To investigate UK medical and nursing undergraduate experience of the surgical safety checklist training.

METHODS

An eight-item electronic questionnaire was distributed electronically to 32 medical schools and 72 nursing schools. Analysis was conducted for the two cohorts, and responses from final year students were included.

RESULTS

87/224 (38.8%) of medical students received teaching on the surgical safety checklist, compared with 380/711 (52.0%) of nursing students. 172/224 (76.8%) of medical students and 489/711 (66.9%) of nursing students understood its purpose and 8/224 (3.6%) medical students and 54/711 (7.4%) nursing students reported never being included in the Time Out. After adjusting for confounding factors, provision of formal teaching in checklist use increased understanding significantly (OR 50.39 (14.07 to 325.79, P<0.001)), as did routine student involvement in time outs (OR 5.72 (2.36 to 14.58, P<0.001)).

DISCUSSION

Knowledge of perioperative patient safety systems and the ability to participate in safety protocols are important skills that should be formally taught at the undergraduate level. Results of this study show that UK undergraduate surgical safety checklist training does not meet the minimum standards set by the WHO.