Going beyond compliance: A qualitative study of the practice of surgical safety checklist

BACKGROUND

The World Health Organization Surgical Safety Checklist (SSC) is a tool designed to enhance team communication and patient safety. When used properly, the SSC acts as a layer of defence against never events. In this study, we performed secondary qualitative analysis of operating theatres (OT) SSC observational notes to examine how the SSC was used after an intensive SSC re-implementation effort and drew on relevant theories to shed light on the observed patterns of behaviours. We aimed to go beyond assessing checklist compliance and to understand potential sociopsychological mechanisms of the variations in SSC practices.

METHODS

Direct observation notes of 109 surgical procedures across 13 surgical disciplines were made by two trained nurses in the OT of a large tertiary hospital in Singapore from February to April 2022, three months after SSC re-implementation. Only notes relevant to the use of SSC were extracted and analyzed using reflexive thematic analysis. Data were coded following an inductive process to identify themes or patterns of SSC practices. These patterns were subsequently interpreted against a relevant theory to appreciate the potential sociopsychological forces behind them.

RESULTS

Two broad types of SSC practices and their respective sub-themes were identified. Type 1 (vs. Type 2) SSC practices are characterized by patience and thoroughness (vs. hurriedness and omission) in carrying out the SSC process, dedication and attention (vs. delegation and distraction) to the SSC safety checks, and frequent (vs. absence of) safety voices during the conduct of SSC. These patterns were conceptualized as safety-seeking action vs. ritualistic action using Merton's social deviance theory.

CONCLUSION

Ritualistic practice of the SSC can undermine surgical safety by creating conditions conducive to never events. To fully realize the SSC's potential as an essential tool for communication and safety, a concerted effort is needed to balance thoroughness with efficiency. Additionally, fostering a culture of collaboration and collegiality is crucial to reinforce and enhance the culture of surgical safety.

Does the WHO Surgical Safety Checklist Need Modification for Orthopaedic Surgery Practices? A Cross-Sectional Survey Among Indian Orthopaedic Surgeons

Background

It is well known that the implementation of the WHO surgical safety checklist (SSC) leads to improved operating room team coordination and reduced perioperative complication and mortality rates. Although it is proven to be beneficial worldwide, its awareness and usage need to be evaluated in a diverse country like India. As orthopaedic surgeries involve implants and tourniquet usage, it is important to evaluate the applicability of WHO SSC specifically to orthopaedic surgeries, and whether any modifications are needed.

Materials and Methods

A web-based cross-sectional survey was conducted among Indian Orthopaedic Surgeons with a pre-defined questionnaire regarding awareness, usage and suggestions to modify the existing WHO SSC (2009) for orthopaedic surgeries.

Results

513 responses were included for final analysis. 90.3% of surgeons were aware of the surgical safety checklist; however, only 55.8% used it routinely in their practice. The awareness of SSC availability was 1.85 times more among younger surgeons (< 20 years of experience) than among those with > 20 years of experience. 17% of surgeons thought the usage of SSC was time-consuming and 52.4% of participants felt a need to modify the existing WHO SSC (2009) for orthopaedic surgeries. 34.5% recommended the inclusion of the patient blood group in the "Sign-in" section, 62.77% proposed the inclusion of details about the tourniquet, whereas only 6.63% suggested adding about surgical implant readiness in the "Time-out" section and 72.7% suggested including a check to make sure the tourniquet was deflated, removed and also recording of the total usage time during the "Sign-out" section.

Conclusion

Despite high (90%) awareness among Indian Orthopaedic surgeons, they have limited usage of the WHO SSC in their practice. Identifying barriers and considering modifications for orthopaedic surgeries, like details about tourniquet usage during the "Time-out" section and a check to ensure it was removed during the "Sign-out" section, will improve patient safety and outcomes.

Graphical Abstract

Supplementary Information

The online version contains supplementary material available at 10.1007/s43465-024-01096-5.

It's not the arrow, it's the archer: the role of the surgeon leader in a safety driven-era

BACKGROUND

In an era where team communication and patient safety are paramount, standardized tools have been deemed critical to safe, efficient practice. In some cases-perhaps most notably in the surgical safety checklist (SSC)-these tools have been elevated as the key to safe patient care. However, effects of the SSC on patient safety in practice remain mixed. We explore the role and impact of the surgeon leader in the use of structured communication tools to understand how surgeon engagement impacts intraoperative teamwork.

METHODS

Using a constructivist grounded theory approach, OR staff members (surgeons, anesthetists, nurses and perfusionists) were recruited to participate in a one-on-one semi-structured interview. The interview explored participant experiences working in the OR, focusing on the role and impact of the surgeon as leader.

RESULTS

Engaged use of the surgical safety checklist by the attending surgeon had the potential to improve teamwork in the operating room. Surgeons who used the checklist to engage with their team and facilitate group discussion were able to avoid tensions later in the operation typically arising from lack of situation awareness and familiarity with team member experience levels. Surgeons who engaged with the SSC as more than a memory aid were able to foster a better team environment.

CONCLUSIONS

Surgeons can harness their role as leader in the operating room by engaging with structured communication tools such as the SSC to foster improved teamwork.

Using i-PARIHS to assess implementation of the Surgical Safety Checklist: an international qualitative study

Background

Strategies selected to implement the WHO’s Surgical Safety Checklist (SSC) are key factors in its ability to improve patient safety. Underutilization of implementation frameworks for informing implementation processes hinders our understanding of the checklists’ varying effectiveness in different contexts. This study explored the extent to which SSC implementation practices could be assessed through the i-PARIHS framework and examined how it could support development of targeted recommendations to improve SSC implementation in high-income settings.

Methods

This qualitative study utilized interviews with surgical team members and health administrators from five high-income countries to understand the key elements necessary for successful implementation of the SSC. Using thematic analysis, we identified within and across-case themes that were mapped to the i-PARIHS framework constructs. Gaps in current implementation strategies were identified, and the utility of i-PARIHS to guide future efforts was assessed.

Results

Fifty-one multi-disciplinary clinicians and health administrators completed interviews. We identified themes that impacted SSC implementation in each of the four i-PARIHS constructs and several that spanned multiple constructs. Within innovation, a disconnect between the clinical outcomes-focused evidence in the literature and interviewees’ patient-safety focus on observable results reduced the SSC’s perceived relevance. Within recipients, existing surgical team hierarchies impacted checklist engagement, but this could be addressed through a shared leadership model. Within context, organizational priorities resulting in time pressures on surgical teams were at odds with SSC patient safety goals and reduced fidelity. At a health system level, employing surgical team members through the state or health region resulted in significant challenges in enforcing checklist use in private vs public hospitals. Within its facilitation construct, i-PARIHS includes limited definitions of facilitation processes. We identified using multiple interdisciplinary champions; establishing checklist performance feedback mechanisms; and modifying checklist processes, such as implementing a full-team huddle, as facilitators of successful SSC implementation.

Conclusion

The i-PARIHS framework enabled a comprehensive assessment of current implementation strategies, identifying key gaps and allowed for recommending targeted improvements. i-PARIHS could serve as a guide for planning future SSC implementation efforts, however, further clarification of facilitation processes would improve the framework’s utility.

Trial registration

No health care intervention was performed.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-08680-1.

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 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.

Surgical Safety Checklist: Polychromatic or Achromatic Design

The Surgical Safety Checklist (SSC) has been created based on the recommendations of the WHO and obligatorily introduced worldwide. SSC is used to increase the patient's safety and reduce complications while in the hospital, especially in the perioperative period. The original SSC template was of a multicolor polychromatic design. However, an achromatic black-and-white or gray-gray design on plain printer paper appears often used in clinical practice. This review aims to assess the level of SSC use in the polychromatic versus achromatic versions and the pros and cons of using either in practice. We used the Google browser for the identification and collection of SSC graphic images available as of June 2021 using the following search commands: "surgical safety checklist WHO" or "surgical safety checklist" or "SSC WHO." The commands were repeated in 103 languages representing the five continents with the back answers provided in 41 languages. The successive top 10 thematically relevant images or fewer if not available in the cases of some foreign languages were considered for analysis, providing a mean of 5 ±2 images per language. The numbers of achromatic and polychromatic two-color or multicolor images were calculated. The number of images corresponding to the respective color designs ranged as follows: 0-6 (27.6%), 0-9 (41.6%), and 0-6 (27.6%) We conclude that polychromatic imaging of SSC documents predominates in practical use. The polychromatic SSC design catches the doctor's eye, which likely increases the effectiveness of completing the document.

"Some version, most of the time": The surgical safety checklist, patient safety, and the everyday experience of practice variation

BACKGROUND

This study investigated checklist compliance to highlight where assumptions about the Surgical Safety Checklist might not be met in practice.

METHODS

We used ethnographic methods to investigate the practice of the Surgical Safety Checklist in one hospital. Fifty-one observation days, eight semi-structured interviews, and two surveys of operating room staff over two years were conducted. Data were collected and analyzed iteratively.

RESULTS

Despite the near 100% compliance rates reported to the Ministry of Health, practice of the Surgical Safety Checklist varied widely: 82% of Briefings, 76% of Time-Outs, and 22% of Debriefings included some sort of team huddle. Gaps between policy and practice were identified at four different levels: compliance with the stages and items; responsibility for the checklist; documentation of adherence; and interprofessional teamwork.

CONCLUSIONS

Checklist compliance data are insufficient to understand how complex interventions impact care delivery. Greater and continued attention to practice in healthcare is needed.

The surgical safety checklist: a quantitative study on attitudes and barriers among gynecological surgery teams

Background

Implementation of the surgical safety checklist (SSC) plays a significant role in improving surgical patient safety, but levels of compliance to a SSC implementation by surgical team members vary significantly. We aimed to investigate the factors affecting satisfaction levels of gynecologists, anesthesiologists, and operating room registered nurses (OR-RNs) with SSC implementation.

Methods

We conducted a survey based on 267 questionnaires completed by 85 gynecologists from 14 gynecological surgery teams, 86 anesthesiologists, and 96 OR-RNs at a hospital in China from March 3 to March 16, 2020. The self-reported questionnaire was used to collect respondent’s demographic information, levels of satisfaction with overall implementation of the SSC and its implementation in each of the three phases of a surgery, namely sign-in, time-out, and sign-out, and reasons for not giving a satisfaction score of 10 to its implementation in all phases.

Results

The subjective ratings regarding the overall implementation of the SSC between the surgical team members were different significantly. “Too many operations to check” was the primary factor causing gynecologists and anesthesiologists not to assign a score of 10 to sign-in implementation. The OR-RNs gave the lowest score to time-out implementation and 82 (85.42%) did not assign a score of 10 to it. “Surgeon is eager to start for surgery” was recognized as a major factor ranking first by OR-RNs and ranking second by anesthesiologists, and 57 (69.51%) OR-RNs chose “Too many operations to check” as the reason for not giving a score of 10 to time-out implementation. “No one initiates” and “Surgeon is not present for ‘sign out’” were commonly cited as the reasons for not assigning a score of 10 to sign-out implementation.

Conclusion

Factors affecting satisfaction with SSC implementation were various. These factors might be essentially related to heavy workloads and lack of ability about SSC implementation. It is advisable to reduce surgical team members’ excessive workloads and enhance their understanding of importance of SSC implementation, thereby improving surgical team members’ satisfaction with SSC implementation and facilitating compliance of SSC completion.

A clinical perspective study on the compliance of surgical safety checklist in all surgical procedures done in operation theatres, in a teaching hospital, Ethiopia, 2021: A clinical perspective study

Background

Patient safety during surgery is an important component for good outcome of operated patients. To discuss an important details about each surgical case; surgical safety checklist is an important patient safety tool that is used by the team of operating room professionals. This study aimed to identify the compliance of surgical safety checklist.

Methods

This clinical perspective study was conducted from February 20 to March 20; 2021 at a teaching referral hospital. All surgical procedures done at a Comprehensive Specialized Teaching Hospital operation theatres were included. Data were collected through direct observation using World Health Organization standard checklist. Descriptive statistics were performed using SPSS version 20.

Results

A total of 100 operations were observed in the main operation theatres of their surgical safety before induction of anaesthesia, before surgical incision and before any team member leave the operation room. From those 100 surgical procedures; patients' identity, procedure and informed consent, anaesthesia machine checking and medication preparations were performed fully (100%) compliance with the standards.

Conclusions

some standards weren't compliant with the standards of WHO surgical safety checklists. We recommend preparing common discussion panel for the operation room team about the performance of the surgical safety checklists and act accordingly.

The surgical debrief: Just another checklist or an instrument to drive cultural change?

INTRODUCTION

Post-procedural debrief is recommended to improve patient safety. We examined operating room (OR) clinicians' perceptions of the impact of a multi-disciplinary debrief on OR culture.

METHODS

A survey was administered to 182 OR clinicians at a major academic medical center. Attitudes toward the surgical debrief and its effect on patient safety and OR culture were evaluated.

RESULTS

Majority of clinicians (58.2%) believed creating a culture of safety in the OR was a shared care team responsibility, however, surgical attendings and trainees were more likely to assign this responsibility to the surgical attending. Few circulating nurses and trainees felt comfortable initiating a surgical debrief. Overall clinicians agreed that a debrief would impact both patient safety outcomes and OR culture.

CONCLUSIONS

Clinicians felt implementation of a surgical debrief would positively affect the OR culture of safety by improving interdisciplinary communication and influencing the power hierarchy that exists in many ORs.

Establishment and implementation of safety check project for invasive procedures outside the operating room

Objective

This study aimed to describe the implementation of the surgical safety check policy and the surgical safety checklist for invasive procedures outside the operating room (OR) and evaluate its effectiveness.

Methods

In 2017, to improve the safety of patients who underwent invasive procedures outside of the OR, the hospital quality and safety committee established the surgery safety check committee responsible for developing a new working plan, revise the surgery safety check policy, surgery safety check form, and provide training to the related staff, evaluated their competency, and implemented the updated surgical safety check policy and checklist. The study compared the data of pre-implementation (Apr to Sep 2017) and two post-implementation phases (Apr to Sep 2018, Apr to Sep 2019). It also evaluated the number of completed surgery safety checklist, correct signature, and correct timing of signature.

Results

The results showed an increase in the completion rate of the safety checklist after the program implementation from 41.7% (521/1,249) to 90.4% (3,572/3,950), the correct rates of signature from 41.9% (218/521) to 99.0% (4,423/4,465), and the correct timing rates of signature from 34.4% (179/521) to 98.5% (4,401/4,465), with statistical significance (P < 0.01).

Conclusion

Implementing the updated surgery safety check significantly is a necessary and effective measure to ensure patient safety for those who underwent invasive procedures outside the OR. Implementing surgical safety checks roused up the clinical staff’s compliance in performing safety checks, and enhanced team collaboration and communication.

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

Background

The World Health Organization Surgical Safety Checklist is an effective tool to reduce morbidity, mortality, perioperative complications, and hospital length of stay. However, its implementation that involves complex social interaction is still challenging.

Objectives

The aim was to increase use of the Surgical Safety Checklist to 100% of performed surgeries compared to current practice at Hospital Moinhos de Vento, in Porto Alegre, Brazil.

Methods

A quality improvement strategy was implemented based on the Plan, Do, Study, Act cycle. During the intervention, Surgical Safety Checklist structure and content were adjusted to the local context and surgeons were engaged in discussions of the medical and scientific basis of the Surgical Safety Checklist. Also, the surgery center nursing team was trained as well as empowered to use the Surgical Safety Checklist.

Results

As compared to baseline data, there was an increase in the use of the tool and data was monitored to evaluate sustainability of the strategy over 26 months. Mean compliance with the Surgical Safety Checklist after the intervention reached 89%. Compliance with the most critical phase – time out – began at 26%. After the intervention, an increase in time out compliance was noted, varying from 60% to 90%.

Conclusion

The proposed quality improvement strategy, implemented at no additional cost to the institution, was effective to increase Surgical Safety Checklist compliance and produced sustainable results.

•

It is the first article of this kind in Brazil. This paper describes the implementation of a quality improvement strategy based on the Plan, Do, Study, Act (PDSA) cycle. The aim was to increase use of the Surgical Safety Checklist to 100% of performed surgeries compared to current practice at Hospital Moinhos de Vento, in Porto Alegre, Brazil.

•

Our data show that adjustment of World Health Organization Surgical Safety Checklist (WHO SSC) structure and content to the local context, as well as engagement of decision-makers and risk management staff to promote WHO SSC compliance contributed to the success of the proposed intervention.

•

Strong points of our quality improvement strategy include the use of an explicit method, namely the Institute for Healthcare Improvement's Plan-Do-Study-Act model, which facilitated the understanding of the intervention/improvement process and allowed us to explore the method's full potential.

Engaging the patient and family in the surgical safety process utilizing

BACKGROUND

Owing to the vulnerable nature of children, parental/caregiver engagement in surgical safety is a crucial aspect of care. Historically, the surgical safety process has been isolated from parent involvement. The digital, tablet-based surgical safety application, SafeStart, requires parent participation and provides multiple instances of verification of patient safety information from preoperative clinic visit, to perioperative care, and into the operating room.

METHOD

The SafeStart application was utilized for 100 pediatric general surgery patients in an IRB approved prospective study. Parent assessments of the surgical consent and safety processes were collected in pre- and postoperative surveys with a 100% response rate. Standard consent forms were used and compared as a control.

RESULTS

Only 31% of parents had knowledge of the surgical safety checklist process prior to their exposure to the study. 96% of the parents reported that the SafeStart patient portal was easy to use. A majority would prefer SafeStart to the standard consent process.

CONCLUSION

The SafeStart program connected the surgical safety process from the preoperative clinic visit through postoperative care. Parent's preferred SafeStart to the standard surgical safety checklist and consent process, felt that they were instrumental in protecting their child's safety, and would recommend SafeStart for the surgical care of others.

LEVEL OF EVIDENCE

II.

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.

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.

Development and Feasibility Testing of a Device Briefing Tool and Training to Improve Patient Safety During Introduction of New Devices in Operating Rooms: Best Practices and Lessons Learned

BACKGROUND

Introducing new surgical devices into the operating room (OR) can serve as a critical opportunity to address patient safety. The effectiveness of OR briefings to improve communication, teamwork, and safety has not been evaluated in this setting.

METHODS

Ariadne Labs and Johnson and Johnson (J&J) collaborated to develop and assess an intervention including a Device Briefing Tool (DBT) and novel multidisciplinary team training for clinicians (surgeons and nurses) around the introduction of a new device in the OR. J&J sales representatives trained clinicians to use the DBT, a communication tool to improve patient safety when a new device is used for the first time. Surveys were administered to representatives (n = 10), surgeons (n = 15), and nurses (n = 30) at the baseline, after trainings, and after using the DBT in an operation at six different Thai hospitals.

RESULTS

Familiarity with the Surgical Safety Checklist (SURGICAL SAFETY CHECKLIST) varied but increased post-training. Regarding trainings, 90% of representatives felt they very much or completely met all learning objectives but 50% felt only slightly prepared to train clinicians on using DBT. Post-training, clinician confidence in using a new device rose from 47 to 85%. Regarding the DBT, 90% of clinicians felt confident using it and reported they were very likely to use it in the future. Overall, over 90% of all clinicians and representatives felt safe having surgery in their hospitals.

CONCLUSIONS

There is high acceptability and feasibility of the multidisciplinary trainings and the DBT among representatives and clinicians, albeit in a limited number of participants from a small number of institutions.

An exploration of surgical team perceptions toward implementation of surgical safety checklists in a non-native English-speaking country

BACKGROUND

In-depth information on the success and failure of implementing the World Health Organization surgical safety checklist (SSC) has been questioned in non-native English-speaking countries. This study explored the experiences of SSC implementation and documented barriers and strategies to improve SSC implementation.

METHODS

A qualitative study was performed in 33 Thai hospitals. The information from focus group discussions with 39 nurses and face-to-face, in-depth interviews with 50 surgical personnel was analyzed using content analysis.

RESULTS

Major barriers were an unclear policy, inadequate personnel, refusals and resistance from the surgical team, English/electronic SSC, and foreign patients. The key strategies to improve SSC implementation were found to be policy management, training using role-play and station-based deconstruction, adapting SSC implementation suitable for the hospital's context, building self-awareness, and patient involvement.

CONCLUSION

The barriers of SSC were related to infrastructure and patients. Effective policy management, teamwork and individual improvement, and patient involvement may be the keys to successful SSC implementation.

An evidence-based intraoperative communication tool for emergency general surgery: a pilot study

BACKGROUND

Emergency general surgery (EGS) is characterized by high rates of morbidity and mortality. Though checklists and associated communication-based huddle strategies have improved outcomes, these tools have never been specifically examined in EGS. We hypothesized that use of an evidence-based communication tool aimed to trigger intraoperative discussion could improve communication in the EGS operating room (OR).

MATERIALS AND METHODS

We designed a set of discussion prompts based on modifiable factors identified from previously published studies aimed to encourage all team members to speak up and to centralize awareness of patient disposition and intraoperative transfusion practices. This tool was pilot-tested using OR human patient simulators and was then rolled out to EGS ORs at an academic medical center. The perceived effect of our tool's implementation was evaluated through mixed-methodologic presurvey and postsurvey analysis.

RESULTS

Preimplementation and postimplementation survey-based data revealed that providers reported the EGS-focused discussion prompts as improving team communication in EGS. A trend toward shared awareness of intraoperative events was observed; however, nurses described cultural impedance of discussion initiation. Providers described a need for further reinforcement of the tool and its indications during implementation.

CONCLUSIONS

Use of a discussion-based communication tool is perceived as supporting team communication in the EGS OR and led to a trend toward improving a shared understanding of intraoperative events. Analyses suggest the need for enhanced reinforcement of use during implementation and improvement of team-based education regarding EGS. Furthermore work is needed to understand the full impact of this evidence-based tool on OR team dynamics and EGS patient outcomes.

Using normalisation process theory to evaluate the implementation of a complex intervention to embed the surgical safety checklist

BACKGROUND

The surgical Safety Checklist (SSC) was introduced in 2008 to improve teamwork and reduce the mortality and morbidity associated with surgery. Although mandated in many health care institutions around the world, challenges in implementation of the SSC continue. To use Normalisation Process Theory (NPT) to help understand how/why implementation of a complex intervention coined Pass The Baton (PTB) could help explain what facets of the Surgical Safety Checklist use led to its' integration in practice, while others were not.

METHODS

A longitudinal multi-method study using survey and interviews was undertaken. Implementation of PTB involved; change champions, audit and feedback, education and prompts. Following implementation, surgical teams were surveyed using the NOrmalization MeAsure Development (NoMAD) and subsequently interviewed to explore the impact of PTB on their use of the checklist at 6 and 12 months respectively. Respondents' self-reported perceptions of implementation of PTB was explained using the four NPT constructs; coherence, cognitive participation, collective action, and reflexive monitoring. Survey data were analysed using descriptive statistics. Interview data were coded inductively and content analysed using a framework derived from NPT.

RESULTS

The NoMAD survey response rate was 59/150 (39.3%). Many (45/59, 77.6%) survey respondents saw the value in PTB, while 50/59 (86.2%) would continue to use it; 45/59 (77.6%) believed that PTB could easily be integrated into existing workflows, and 48/59 (82.8%) thought that feedback could improve PTB in the future. A total of 8 interviews were completed with 26 surgical team members. Nurses and physicians held mixed views towards coherence while buy-in and participation relied on individuals' investment in the implementation process and the ability to modify PTB. Participants generally recognised the benefit and value of using PTB in the ongoing implementation the checklist.

CONCLUSIONS

Workarounds and flexible co-construction in implementation designed to improve team communications in surgery may facilitate their normalisation in practice.

Implementation of the surgical safety checklist at a tertiary academic center: Impact on safety culture and patient outcomes

BACKGROUND

The impact and efficacy of the World Health Organization Surgery Safety Checklist (SSC) is uncertain. We sought to determine if the SSC decreases complications and examined the attitudes of the surgical team members following implementation of the SSC.

METHODS

A 28-question survey was developed to assess perspectives of surgical team members at the University of Vermont Medical Center (UVMC). The University Health System Consortium database was examined to compare the rates of nine complications before and after SSC implementation using Chi square analysis and Fisher's exact test.

RESULTS

There was no significant decrease in any of the nine complications 2 years after SSC implementation. There was overall agreement that the SSC improved communication, safety, and prevented errors in the operating room. However, there was disagreement between nursing and surgeons over whether all three parts of the SSC were always completed.

CONCLUSIONS

Implementation of the SSC did not result in a significant decrease in perioperative morbidity or mortality. However, it did improve the perception of safety culture by operating room staff.

[Compliance with the surgical safety checklist and surgical events detected by the Global Trigger Tool]

INTRODUCTION

The implementing of the WHO Surgical Safety Checklist (SSC) has helped to improve patient safety. The aim of this study was to assess the level of compliance of the SSC, and incorporating the non-compliances as «triggers» in the Global Trigger Tool (GTT).

MATERIAL AND METHODS

SETTING

Acute Geriatric Hospital (200 beds). Retrospective study, study period: 2011-2014. The SSC formulary and the methodology of the GTT were used for the analysis of electronic medical records and the compliance with the SSC. The NCCP MERP categories were used to assess the severity of the harm.

RESULTS

Out of all the electronic medical records (EMR), a total of 227 (23.6%) discharged patients (1.7% of interventions in the four year study period) were analysed. All (100%) of the EMR included the SSC, with 94.4% of the items being completed, and 28.2% of SSC had all items completed in the 3 phases of the process. Surgical adverse events decreased from 16.3% in 2011 to 9.4% in 2014 (P=.2838, not significant), and compliance with all items of SSC was increased from 18.6% to 39.1% (P=.0246, significant).

CONCLUSIONS

The GTT systematises and evaluates, at low cost, the triggers and incidents/ AEs found in the EMR in order to assess the compliance with the SSC and consider non-compliance of SSC as «triggers» for further analysis. This strategy has never been referred to in the GTT or in the SCC formulary.

A multifaceted prevention program to reduce infection after cesarean section: Interventions assessed using an intensive postdischarge surveillance system

BACKGROUND

We assessed the effects of the components of a multifaceted and evidence-based caesarean-section surgical site infection (SSI) prevention program on the SSI rate after cesarean section using a postdischarge surveillance (PDS) system.

METHODS

Multiple prevention interventions were serially implemented. SSI case finding was undertaken through active inpatient surveillance and intensive PDS using a standardized form at the 6-week postdischarge visit. SSI diagnosis was made using the Centers for Disease Control and Prevention standardized criteria. All cesarean deliveries between July 2007 and December 2012 were included. Changes in SSI rate were analyzed using segmented regression analysis.

RESULTS

Nine thousand four hundred forty-two cesarean sections were assessed during the study period. PDS forms were completed for 7,985 women (85%). SSI was detected in 451 cases (5.6%): 91% were superficial, 9% were deep/organ-space infections. The SSI rate decreased incrementally from 8.2% at baseline to 4.1%; significant decreases were observed after optimizing antibiotic prophylaxis timing, using a surgical safety checklist, and enhancing prenatal education to discourage prehospital self-removal of hair. Nonelective surgeries or those undertaken after >12 hours of rupture of membranes had a significantly higher rate compared with those without either risk factor (6.3% vs 3.2%; P < .001).

CONCLUSIONS

A multifaceted SSI prevention strategy, with periodic feedback of data, led to a significant reduction in SSI rates after cesarean section.