Quality improvement strategy to enhance compliance with the World Health Organization Surgical Safety Checklist in a large hospital: Quality improvement study

Use of Technology to Improve the Adherence to Surgical Safety Checklists in the Operating Room

BACKGROUND

Although checklists can improve safety in the operating room (OR), compliance with their use is variable. Use of a forcing function, a principle of human factors engineering, has not been reported earlier as a method of increasing checklist use. The authors conducted this study to determine the feasibility and effects of introducing a forcing function on OR surgical safety checklist implementation and adherence.

METHODS

The authors developed and introduced the use of an electronic version of the surgical safety checklist on an Android application, provided on a personal device available in the OR. This application was linked by Bluetooth to electrocautery equipment, which could not be started before the electronic checklist was completed on the screen of the personal device. In the same OR, retrospective data from use of the traditional (paper-based) checklist were compared with data from the new electronic checklist for frequency of use, and completeness (percentage of all checklist items completed) at three stages of the surgical process-sign-in, time-out, and sign-out.

RESULTS

The frequency of use was 100.0% for the electronic checklist, compared with 97.9% for the traditional checklist. The frequency of completeness was 27.1% for the traditional vs. 100.0% for the electronic (p < 0.001).The manual checklist's sign-out component was completed only 37.0% of the time.

CONCLUSION

Although checklist use in some form was already high with the traditional checklist, completion rate was low and significantly increased with the use of the electronic checklist with a forcing function.

Improving safety in anesthetized patients undergoing magnetic resonance imaging-Concept of time-out in the MRI suite and measures to improve adherence to time-out protocol

BACKGROUND

The time-out protocol introduced by the Joint Commission is an important tool to prevent adverse events and improve safety in various health-care environments. However, its implementation and utilization involve human, social, behavioral as well as system issues.

AIMS

The SMART aim of the current project was to increase the utilization of the time-out protocol to more than 80% from baseline of 13%, over 6-month period in all the magnetic resonance imaging (MRI) procedures performed at a tertiary care, teaching institute in South India.

METHODS

The Plan, Do, Study, Act (PDSA) cycle and root cause analysis strategies were utilized in this quality improvement initiative. The time-out protocol was modified for MRI environment and put into practice to improve safety. Six months after the initiation of this safety protocol, our audit showed only a 13% compliance to the time-out protocol. A multimodal strategy was utilized by involving all the stakeholders, educational interventions, and placing reminders for following the time-out protocol, to affect change and achieve improvement in safety.

RESULTS

The compliance to time-out protocol increased from 13% to 86% and the run chart showed that a special cause variation indicated by six points above the centerline at 86%. When analyzing individual components of the time-out, the greatest improvement was noted in the ferromagnetic check of the personnel involved, namely, the Anesthesiologist, radiographer, and anesthesia technician. There were no delays in the list because of adherence to the time-out protocol.

CONCLUSION

Time-out protocol in an MRI suite provides a final check to the anesthesia team before the anesthetized patient is wheeled into MR gantry. Using quality improvement methodology, we increased the compliance of time-out protocol in the magnetic resonance imaging environment. Our study is an example how other institutions in India and elsewhere can adapt similar improvement strategies to enhance patient safety.

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.

An evidence-based general anaesthesia and prone position nursing checklist: Development and testing

AIM

Prone positioning during general anaesthesia is one of the most difficult practices for the perioperative nurse. Patients in this position are vulnerable to many preventable complications. However, no studies have developed an evidence-based tool to improve nursing practice during general anaesthesia and prone positioning. This study aimed to develop and test a general anaesthesia and prone position nursing checklist for use by the circulating nurse.

DESIGN

A prospective pre-post study was performed between October 2020 and March 2021.

METHODS

The WHO checklist development model and evidence-based methods guided the checklist development process. We prospectively observed circulating nurses that attended to prone general anaesthesia during posterior lumbar spine surgery for 3 months before and after the introduction of the general anaesthesia and prone position nursing risk checklist. The main outcomes were successful delivery of essential prone positional nursing practices during each surgery and the nurse's opinion of the checklist's efficacy and utility.

RESULTS

A general anaesthesia and prone position nursing checklist comprised of 4 pause points and 22 necessary nursing practices was developed. Seventy-two nurses participated in this study. Use of the checklist significantly increased the average performance of essential practices during each surgery from 72.72%-95.45%. Three measures had a compliance rate of 100%. The delivery rate of 14 measures was significantly improved, 91.7% of nurses considered the checklist easy to use, and 94.4% nurses would want the checklist to be used if they underwent a prone position and general anaesthesia operation.

Perioperative provider safety in the pandemic: Development, implementation and evaluation of an adjunct COVID-19 Surgical Patient Checklist

The COVID-19 pandemic has strained surgical systems worldwide and placed healthcare providers at risk in their workplace. To protect surgical care providers caring for patients with COVID-19, in May 2020 we developed a COVID-19 Surgical Patient Checklist (C19 SPC), including online training materials, to accompany the World Health Organization Surgical Safety Checklist. In October 2020, an online survey was conducted via partner and social media networks to understand perioperative clinicians’ intraoperative practice and perceptions of safety while caring for COVID-19 positive patients and gain feedback on the utility of C19 SPC. Descriptive statistics were used to characterise responses by World Bank income classification. Qualitative analysis was performed to describe respondents' perceptions of C19 SPC and recommended modifications. Respondents included 539 perioperative clinicians from 63 countries. One-third of respondents reported feeling unsafe in their workplace due to COVID-19 with significantly higher proportions in low (39.8%) and lower-middle (33.9%) than higher income countries (15.6%). The most cited concern was the risk of COVID-19 transmission to self, colleagues and family. A large proportion of respondents (65.3%) reported that they had not used C19 SPC, yet 83.8% of these respondents felt it would be useful. Of those who reported that they had used C19 SPC, 62.0% stated feeling safer in the workplace because of its use. Based on survey results, modifications were incorporated into a subsequent version. Our survey findings suggest that perioperative clinicians report feeling unsafe at work during the COVID-19 pandemic. In addition, adjunct tools such as the C19 SPC can help to improve perceived safety.

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.

Increasing use of an endotracheal intubation safety checklist in the emergency department

Endotracheal intubation (ETI) is a high-risk procedure often performed in the emergency department (ED) in critically unwell patients. The fourth National Audit Project by The Royal College of Anaesthetists found the risk of adverse events is much higher when performing the intervention in this setting compared with a theatre suite, and therefore use of a safety checklist is recommended. This quality improvement project was set in a large teaching hospital in the North West of the UK, where anaesthesia and intensive care clinicians are responsible for performing this procedure. A retrospective baseline audit indicated checklist use was 16.7% of applicable cases. The project aim was to increase the incidence of checklist use in the ED to 90% within a 6-month period. The model for improvement was used as a methodological approach to the problem along with other quality improvement tools, including a driver diagram to generate change ideas. The interventions were targeted at three broad areas: awareness of the checklist and expectation of use, building a favourable view of the benefits of the checklist and increasing the likelihood it would be remembered to use the checklist in the correct moment. After implementation checklist use increased to 84%. In addition, run chart analysis indicated a pattern of nonrandom variation in the form of a shift. This coincided with the period shortly after the beginning of the interventions. The changes were viewed favourably by junior and senior anaesthetists, as well as operating department practitioners and ED staff. Limitations of the project were that some suitable cases were likely missed due to the method of capture and lack of anonymous qualitative feedback on the changes made. Overall, however, it was shown the combination of low-cost interventions made was effective in increasing checklist use when performing emergency ETI in the ED.

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.

A Scoping Review of Strategies Used to Implement the Surgical Safety Checklist

In 2007, the World Health Organization initiated the Surgical Safety Checklist (SSC) as part of an initiative to improve patient outcomes. After publication of the SSC, perioperative nurses identified challenges with implementing it and questioned its effectiveness. We desired to summarize the state of the science on the effectiveness of strategies that perioperative personnel have used to implement and assess the SSC; therefore, we conducted a scoping review. We searched several databases and identified 28 articles that described the three key stages of SSC implementation (ie, before, during, and after). Half of the identified articles addressed intervention strategies and most articles provided strategies for SSC implementation. The literature also indicated that effective implementation occurred when there was adequate planning. Perioperative leaders should work with nurses when implementing the SSC and monitor its use after implementation to verify compliance and help prevent negative patient outcomes.

Safe surgery checklist: evaluation in a neotropical region

OBJECTIVE

assess patient responses and associated factors of items on a safe surgery checklist, and identify use before and after protocol implementation from the records.

METHODS

a cohort study conducted from 2014 to 2016 with 397 individuals in stage I and 257 in stage II, 12 months after implementation, totaling 654 patients. Data were obtained in structured interviews. In parallel, 450 checklist assessments were performed in medical records from public health institutions in the Southwest II Health Region of Goiás state, Brazil.

RESULTS

six items from the checklist were evaluated and all of these exhibited differences (p < 0.000). Of the medical records analyzed, 69.9% contained the checklist in stage I and 96.5% in stage II, with better data completeness. In stage II, after training, the checklist was associated with surgery (OR; 1.38; IC95%: 1.25-1.51; p < 0.000), medium-sized hospital (OR; 1.11; CI95%; 1.0-1.17; p < 0.001), male gender (OR; 1.07; CI95%; 1.0-1.14; p < 0.010), type of surgery (OR; 1.7; CI95%: 1.07-1.14; p < 0.014) and antibiotic prophylaxis 30 to 60 min after incision (OR; 1.10; CI95%: 1.04-1.17; p < 0.000) and 30 to 60 min after surgery (OR; 1.23; CI95%: 1.04-1.45; p = 0.015).

CONCLUSIONS

the implementation strategy of the safe surgery checklist in small and medium-sized healthcare institutions was relevant and associated with better responses based on patient, data availability and completeness of the data.