A ‘paperless’ wall-mounted surgical safety checklist with migrated leadership can improve compliance and team engagement

Transforming Team Performance Through Reimplementation of the Surgical Safety Checklist

Importance

Patient safety interventions, like the World Health Organization Surgical Safety Checklist, require effective implementation strategies to achieve meaningful results. Institutions with underperforming checklists require evidence-based guidance for reimplementing these practices to maximize their impact on patient safety.

Objective

To assess the ability of a comprehensive system of safety checklist reimplementation to change behavior, enhance safety culture, and improve outcomes for surgical patients.

Design, Setting, and Participants

This prospective type 2 hybrid implementation-effectiveness study took place at 2 large academic referral centers in Singapore. All operations performed at either hospital were eligible for observation. Surveys were distributed to all operating room staff.

Intervention

The study team developed a comprehensive surgical safety checklist reimplementation package based on the Exploration, Preparation, Implementation, Sustainment framework. Best practices from implementation science and human factors engineering were combined to redesign the checklist. The revised instrument was reimplemented in November 2021.

Main Outcomes and Measures

Implementation outcomes included penetration and fidelity. The primary effectiveness outcome was team performance, assessed by trained observers using the Oxford Non-Technical Skills (NOTECH) system before and after reimplementation. The Agency for Healthcare Research and Quality Hospital Survey on Patient Safety Culture was used to assess safety culture and observers tracked device-related interruptions (DRIs). Patient safety events, near-miss events, 30-day mortality, and serious complications were tracked for exploratory analyses.

Results

Observers captured 252 cases (161 baseline and 91 end point). Penetration of the checklist was excellent at both time points, but there were significant improvements in all measures of fidelity after reimplementation. Mean NOTECHS scores increased from 37.1 to 42.4 points (4.3 point adjusted increase; 95% CI, 2.9-5.7; P < .001). DRIs decreased by 86.5% (95% CI, -22.1% to -97.8%; P = .03). Significant improvements were noted in 9 of 12 composite areas on culture of safety surveys. Exploratory analyses suggested reductions in patient safety events, mortality, and serious complications.

Conclusions and Relevance

Comprehensive reimplementation of an established checklist intervention can meaningfully improve team behavior, safety culture, patient safety, and patient outcomes. Future efforts will expand the reach of this system by testing a structured guidebook coupled with light-touch implementation guidance in a variety of settings.

Interventions to facilitate interprofessional collaboration in the operating theatre: A scoping review

BACKGROUND

Ineffective collaboration can increase adverse events in the operating theatre. When professionals work collaboratively, they are more likely to improve patient safety and outcomes.

AIM

To identify interprofessional collaboration interventions involving operating theatre teams and describe their effect on facilitating communication, teamwork, and safety.

METHODS

A scoping review of four databases. Results were analysed by identifying interventions and mapping their related outcomes.

RESULTS

Twenty studies evaluated single or multi-faceted interventions. Despite low-quality study designs (no randomised controlled trials), four interventions (eg: briefings, checklists, team training, debriefing) improved communication and teamwork, and enhanced safety outcomes. Only one study, using team training, reported that organisational level interventions (eg: Standard Operating Procedures, Lean quality improvement management system) improved teamwork and safety outcomes.

CONCLUSION

Several studies reported interventions enhanced interprofessional collaboration within operating theatre teams. Although findings were in favour of improved communication and teamwork, more rigorous research is required.

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.

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.

Safety Attitude of Operating Room Personnel Associated With Accurate Completion of a Surgical Checklist: A Cross-sectional Observational Study

OBJECTIVE

How the checklist is executed in routine practice may reflect the teamwork and safety climate in the operating room (OR). This cross-sectional study aimed to identify whether the presence of a fully completed checklist in medical records was associated with teams' safety attitudes.

METHODS

Data from 29 French hospitals, including 5677 operated patients and 834 OR professionals, were prospectively collected. The degree of checklist compliance was categorized for each patient in 1 of 4 ways: full, incomplete, inaccurate, and no checklist completed. The members of OR teams were invited to complete a questionnaire including teamwork climate measurement (Safety Attitudes Questionnaire) and their opinion regarding checklist use, checklist audibly reading, and communication change with checklist. Multilevel modeling was performed to investigate the effect of variables related to hospitals and professionals on checklist compliance, after adjustment for patient characteristics.

RESULTS

A checklist was present for 83% of patients, but only 35% demonstrated full completion. Compared with no checklist, full completion was associated with higher safety attitude (high teamwork climate [adjusted odds ratio for full completion, 4.14; 95% confidence interval, 1.75-9.76]; communication change [1.31, 1.04-1.66]; checklist aloud reading [1.16, 1.02-1.32]) and was reinforced by the designation of a checklist coordinator (2.43, 1.06-5.55). Incomplete completion was also associated with enhanced safety attitude contrary to inaccurate completion.

CONCLUSIONS

Compliance with checklists is associated with safer OR team practice and can be considered as an indicator of the extent of safety in OR practice.

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.

Surgical team perceptions of the surgical safety checklist in a tertiary hospital in Jordan: a descriptive qualitative study

Purpose

The purpose of this paper is to explore the perceptions of operating room staff towards the use of the World Health Organization Surgical Safety Checklist in a tertiary hospital in Jordan.

Design/methodology/approach

This was a qualitative descriptive study. Semi-structured interviews were conducted with a purposeful sample of 21 healthcare staff employed in the operating room (nurses, residents, surgeons and anaesthesiologists). The interviews were conducted in the period from October to December 2021. Thematic analysis was used to analyse the data.

Findings

Three main themes emerged from data analysis namely compliance with the surgical safety checklist, the impact of surgical safety checklist, and barriers and facilitators to the use of the surgical safety checklist. The use of the checklist was seen as enabling staff to communicate effectively and thus to accomplish patient safety and positive outcomes. The perceived barriers to compliance included excessive workload, congestion and lack of training and awareness. Enhanced training and education were thought to improve the utilization of the surgical safety checklist, and help enhance awareness about its importance.

Originality/value

While steps to utilize the surgical safety checklist by the operation room personnel may seem simple, the quality of its administration is not necessarily robust. There are several challenges for consistent, complete and effective administration of the surgical safety checklist by the surgical team members. Healthcare managers must employ interventions to eliminate barriers to and offer facilitators of adherence to the application of the surgical safety checklist, therefore promoting quality healthcare and patient safety.

Perceptions from nurses, surgeons, and anesthetists about the use and benefits of the surgical checklist in a teaching hospital

OBJECTIVE

To assess attitudes and perceptions from nursing staff, surgeons and anesthetists about compliance, utility, and impact on patient's safety of the surgical checklist in a teaching hospital. We also aimed to identify improvement opportunities for strengthening the usefulness of the checklist in the operating theater.

METHODS

We carried out a questionnaire-based an observational cross-sectional study. A questionnaire was distributed to operating room staff, including nursing staff, surgeons, and anesthetists. In addition to the information about surgical checklist, We also collected information regarding years of experience in the operating theater. Fisher's exact was used to compare proportions in each statement. Group discussion meetings with key professionals were held to jointly assess the results, propose improvement actions, and evaluate their feasibility.

RESULTS

The overall response rate was 36.2% (131/362). Nursing staff was perceived as the most supportive group in the use of surgical checklist. A 64.3% of surgeons considered that using the checklist prevented adverse events vs 84.2% and 85.7% among anesthetists and nurses, respectively; p=0.028. Junior staff showed a supportive attitude toward the use of surgical checklist, considering it as a tool that gives them confidence. We ended up with a list of improvement actions aiming at strengthening the surgical checklist reliability and compliance.

CONCLUSIONS

The perception of the surgical checklist usefulness as a tool to prevent adverse events was moderate among surgeons, but well appreciated by junior staff. Nursing staff were especially critical regarding compliance and support by other professionals. To reinforce the usefulness perception of the surgical checklist it is needed to increase the involvement of all professionals, especially senior staff and surgical leaders.

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 retrospective audit of postoperative days alive and out of hospital, including before and after implementation of the WHO surgical safety checklist

We implemented the World Health Organization surgical safety checklist at Auckland City Hospital from November 2007. We hypothesised that the checklist would reduce postoperative mortality and increase days alive and out of hospital, both measured to 90 postoperative days. We compared outcomes for cohorts who had surgery during 18-month periods before vs. after checklist implementation. We also analysed outcomes during 9 years that included these periods (July 2004-December 2013). We analysed 9475 patients in the 18-month period before the checklist and 10,589 afterwards. We analysed 57,577 patients who had surgery from 2004 to 2013. Mean number of days alive and out of hospital (95%CI) in the cohort after checklist implementation was 1.0 (0.4-1.6) days longer than in the cohort preceding implementation, p < 0.001. Ninety-day mortality was 395/9475 (4%) and 362/10,589 (3%) in the cohorts before and after checklist implementation, multivariable odds ratio (95%CI) 0.93 (0.80-1.09), p = 0.4. The cohort changes in these outcomes were indistinguishable from longer-term trends in mortality and days alive and out of hospital observed during 9 years, as determined by Bayesian changepoint analysis. Postoperative mortality to 90 days was 228/5686 (4.0%) for Māori and 2047/51,921 (3.9%) for non-Māori, multivariable odds ratio (95%CI) 0.85 (0.73-0.99), p = 0.04. Māori spent on average (95%CI) 1.1 (0.5-1.7) fewer days alive and out of hospital than non-Māori, p < 0.001. In conclusion, our patients experienced improving postoperative outcomes from 2004 to 2013, including the periods before and after implementation of the surgical checklist. Māori patients had worse outcomes than non-Māori.

Communication and team function affect patient outcomes in anaesthesia: getting the message across

A study in this edition of the Journal has added to data showing that failures in communication in the operating room contribute to patient harm. These data support the view that multidisciplinary teamwork and communication training should be part of the continuous professional development of all members of the perioperative team. Achieving change will require efforts to win the hearts and minds of all concerned, but these data also support an expectation that engagement in initiatives and techniques to enhance communication and teamwork should not be optional.

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.

Implementation and adherence to a speciality-specific checklist for neurosurgery and its influence on patient safety

Background and Aims

Neurosurgery involves a high level of expertise coupled with enduring and long duration of working hours. There is a paucity of published literature about the experience with a speciality-specific checklist in neurosurgery. We conducted a cross-sectional observational study to identify the adherence to various elements of the Modified World Health Organization Surgical Safety Checklist (WHO SSC) for neurosurgery by the operating room (OR) team.

Methods

We implemented an intra-operative Modified WHO SSC consisting of 40 tools for neurosurgery, in 200 consecutive elective cases. Trained anaesthesiologists assumed the role of checklist co-ordinator. The checklist divided the surgery into 5 phases, each corresponding to a specific time-period. The adherence rates to various tools were evaluated and areas where the checklist prompted a corrective measure were analysed.

Results

A total of 131 cases undergoing craniotomy and 69 cases undergoing spine surgery were studied. With the 40-point modified SSC applied in 200 cases, we analysed a total of 8000 observations. The modified checklist prompted the OR team to adhere to speciality-specific safety practices about application of compression stockings (9.5%); airway precautions in unstable cervical spine (2.5%); precautions for treatment of raised intracranial pressure (10.5%); and intraoperative neuro-monitoring (5%).

Conclusion

The implementation of Modified WHO SSC for Neurosurgery, by a designated checklist co-ordinator, can rectify anaesthetic and surgical facets promptly, without increasing the OR time. The anaesthesiologist as SSC coordinator can effectively implement an intraoperative checklist ensuring excellent participation of operating room team members.

Aviation-Style Computerized Surgical Safety Checklist Displayed on a Large Screen and Operated by the Anesthesia Provider Improves Checklist Performance

BACKGROUND

Many hospitals have implemented surgical safety checklists based on the World Health Organization surgical safety checklist, which was associated with improved outcomes. However, the execution of the checklists is frequently incomplete. We reasoned that aviation-style computerized checklist displayed onto large, centrally located screen and operated by the anesthesia provider would improve the performance of surgical safety checklist.

METHODS

We performed a prospective before and after observational study to evaluate the effect of a computerized surgical safety checklist system on checklist performance. We created checklist software and translated our 4-part surgical safety checklist from wall poster into an aviation-style computerized format displayed onto a large, centrally located screen and operated by the anesthesia provider. Direct observers recorded performance of the first part of the surgical safety checklist that was initiated before anesthetic induction, including completion of each checklist item, provider participation and distraction level, resistance to use of the checklist, and the time required for checklist completion before and after checklist system implementation. We compared trends of the proportions of cases with 100% surgical safety checklist completion over time between pre- and postintervention periods and assessed for a jump at the start of intervention using segmented logistic regression model while controlling for potential confounding variables.

RESULTS

A total of 671 cases were observed before and 547 cases were observed after implementation of the computerized surgical safety checklist system. The proportion of cases in which all of the items of the surgical safety checklist were completed significantly increased from 2.1% to 86.3% after the computerized checklist system implementation (P < .001). Before computerized checklist system implementation, 488 of 671 (72.7%) cases had <75% of checklist items completed, whereas after a computerized checklist system implementation, only 3 of 547 (0.5%) cases had <75% of checklist items completed.

CONCLUSIONS

The implementation of a computerized surgical safety checklist system resulted in an improvement in checklist performance.

Surgical safety checklist: benefits, facilitators, and barriers in the nurses' perspective

OBJECTIVE

To identify the benefits, facilitators and barriers in the implementation of the surgical safety checklist, according to the reports of nurses working in the hospital surgical center.

METHOD

Cross-sectional study with 91 nurses in 25 hospitals in two municipalities of Paraná. Between the years 2015 and 2016, two structured instruments were used to collect data. For the analysis, Fisher's exact or Chi-Square test was used.

RESULTS

The implementation of the checklist brought benefits to the patient, surgical team and hospitals. Regarding the facilitators, the results presented a statistically significant difference between the groups in the items offering education (p=0.006) and acceptance by surgeons (p=0.029). In the barriers, the lack of administrative (p=0.006) and management (p=0.041) support, absence of the patient safety nucleus (p=0.005), abruptly introduced list (p=0.001) and absence of education (p<0.001).

CONCLUSION

The evidence generated allowed to identify the benefits, facilitators and barriers in the implementation of the checklist in the national context.

Examining reliability of WHOBARS: a tool to measure the quality of administration of WHO surgical safety checklist using generalisability theory with surgical teams from three New Zealand hospitals

OBJECTIVES

To extend reliability of WHO Behaviourally Anchored Rating Scale (WHOBARS) to measure the quality of WHO Surgical Safety Checklist administration using generalisability theory. In this context, extending reliability refers to establishing generalisability of the tool scores across populations of teams and raters by accounting for the relevant sources of measurement errors.

DESIGN

Cross-sectional random effect measurement design assessing surgical teams by the five items on the three Checklist phases, and at three sites by two trained raters simultaneously.

SETTING

The data were collected in three tertiary hospitals in Auckland, New Zealand in 2016 and included 60 teams observed in 60 different cases with an equal number of teams (n=20) per site. All elective and acute cases (adults and children) involving surgery under general anaesthesia during normal working hours were eligible.

PARTICIPANTS

The study included 243 surgical staff members, 138 (50.12%) women.

MAIN OUTCOME MEASURE

Absolute generalisability coefficient that accounts for variance due to items, phases, sites and raters for the WHOBARS measure of the quality of WHO Surgical Safety Checklist administration.

RESULTS

The WHOBARS in its present form has demonstrated good generalisability of scores across teams and raters (G absolute=0.83). The largest source of measurement error was the interaction between the surgical team and the rater, accounting for 16.7% (95% CI 16.4 to 16.9) of the total variance in the data. Removing any items from the WHOBARS led to a decrease in the overall reliability of the instrument.

CONCLUSIONS

Assessing checklist administration quality is important for promoting improvement in its use, and WHOBARS offers a reliable approach for doing this.

Implementation process of the Surgical Safety Checklist: integrative review

Objective:

to analyze the evidence available in the literature on the process of implementing the Surgical Safety Checklist, proposed by the World Health Organization, in the practice of health services.

Method:

integrative review, the search for primary studies was performed in three relevant databases in the health area, and the sample consisted of 27 studies, which were grouped into three categories.

Results:

the synthesis of the evidence indicated the different strategies that can be adopted in the implementation process (introduction and optimization) of the Surgical Safety Checklist, and the facilitators and barriers that determine the success in using this tool.

Conclusion:

in health services, implementing the checklist is a complex and challenging process that requires effective leadership, clear delegation of responsibilities from each professional, collaboration between team members, and institutional support. The synthesis of the generated knowledge can assist nurses in decision making, especially in identifying strategies for the effective implementation of the Surgical Safety Checklist, since nursing has the potential to be a protagonist in the planning and implementation of best practices for patient safety.

Improving the quality of administration of the Surgical Safety Checklist: a mixed methods study in New Zealand hospitals

While the WHO Surgical Safety Checklist (the Checklist) can improve patient outcomes, variable administration can erode benefits. We sought to understand and improve how operating room (OR) staff use the Checklist. Our specific aims were to: determine if OR staff can discriminate between good and poor quality of Checklist administration using a validated audit tool (WHOBARS); to determine reliability and accuracy of WHOBARS self-ratings; determine the influence of demographic variables on ratings and explore OR staff attitudes to Checklist administration.

DESIGN

Mixed methods study using WHOBARS ratings of surgical cases by OR staff and two independent observers, thematic analysis of staff interviews.

PARTICIPANTS

OR staff in three New Zealand hospitals.

OUTCOME MEASURES

Reliability of WHOBARS for self-audit; staff attitudes to Checklist administration.

RESULTS

Analysis of scores (243 participants, 2 observers, 59 cases) supported tool reliability, with 87% of WHOBARS score variance attributable to differences in Checklist administration between cases. Self-ratings were significantly higher than observer ratings, with some differences between professional groups but error variance from all raters was less than 10%. Key interview themes (33 interviewees) were: Team culture and embedding the Checklist, Information transfer and obstacles, Raising concerns and 'A tick-box exercise'. Interviewees felt the Checklist could promote teamwork and a safety culture, particularly enabling speaking up. Senior staff were of key importance in setting the appropriate tone.

CONCLUSIONS

The WHOBARS tool could be useful for self-audit and quality improvement as OR staff can reliably discriminate between good and poor Checklist administration. OR staff self-ratings were lenient compared with external observers suggesting the value of external audit for benchmarking. Small differences between ratings from professional groups underpin the value of including all members of the team in scoring. We identified factors explaining staff perceptions of the Checklist that should inform quality improvement interventions.

The Role of Checklists and Human Factors for Improved Patient Safety in Plastic Surgery

LEARNING OBJECTIVES

After studying the article, participants should be able to: 1. Describe the role of human factors and nontechnical skills for patient safety and recognize the need for customization of surgical checklists. 2. Apply encouragement to speaking up and understand the importance of patient involvement for patient safety. 3. Recognize the potential for improvement regarding patient safety in their own environment and take a leading role in the patient safety process. 4. Assess their own safety status and develop measures to avoid unnecessary distraction in the operating room.

SUMMARY

Over the past 20 years, there has been increased attention to improving all aspects of patient safety and, in particular, the important role of checklists and human factors. This article gives a condensed overview of selected aspects of patient safety and aims to raise the awareness of the reader and encourage further study of referenced literature, with the goal of increased knowledge and use of proven safety methods. The CME questions should help indicate where there is still potential for improvement in patient safety, namely, in the field of nontechnical skills.