Effects of the Introduction of the WHO "Surgical Safety Checklist" on In-Hospital Mortality A Cohort Study

Division of Perioperative Care and Emergency Medicine, University Medical Centre Utrecht, Utrecht, NL.
Annals of surgery (Impact Factor: 8.33). 11/2011; 255(1):44-9. DOI: 10.1097/SLA.0b013e31823779ae
Source: PubMed


To evaluate the effect of implementation of the WHO's Surgical Safety Checklist on mortality and to determine to what extent the potential effect was related to checklist compliance.
Marked reductions in postoperative complications after implementation of a surgical checklist have been reported. As compliance to the checklists was reported to be incomplete, it remains unclear whether the benefits obtained were through actual completion of a checklist or from an increase in overall awareness of patient safety issues.
This retrospective cohort study included 25,513 adult patients undergoing non-day case surgery in a tertiary university hospital. Hospital administrative data and electronic patient records were used to obtain data. In-hospital mortality within 30 days after surgery was the main outcome and effect estimates were adjusted for patient characteristics, surgical specialty and comorbidity.
After checklist implementation, crude mortality decreased from 3.13% to 2.85% (P = 0.19). After adjustment for baseline differences, mortality was significantly decreased after checklist implementation (odds ratio [OR] 0.85; 95% CI, 0.73-0.98). This effect was strongly related to checklist compliance: the OR for the association between full checklist completion and outcome was 0.44 (95% CI, 0.28-0.70), compared to 1.09 (95% CI, 0.78-1.52) and 1.16 (95% CI, 0.86-1.56) for partial or noncompliance, respectively.
Implementation of the WHO Surgical Checklist reduced in-hospital 30-day mortality. Although the impact on outcome was smaller than previously reported, the effect depended crucially upon checklist compliance.

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    • "Yuan et al. [13] report the effects of a successful implementation in Liberia with a significant improvement in surgical processes and outcomes, but with variations seen at the institutional level suggesting that the process, and outcomes, of implementation are highly context-dependent [13]. An earlier cohort study by van Klei et al. [12] supports the intuitively reasonable idea that Checklist effectiveness will be directly linked to the effectiveness of implementation [15]. Rowe et al. [16] highlight the relative effectiveness of a combined managerial and educational approach using group processes, supervision, audit and feedback to improve quality in low resource settings, and this appears to be borne out in experience to date of Checklist implementation in these settings [16]. "
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    ABSTRACT: The WHO Surgical Safety Checklist has a growing evidence base to support its role in improving perioperative safety, although its impact is likely to be directly related to the effectiveness of its implementation. There remains a paucity of documented experience from low-resource settings on Checklist implementation approaches. We report an implementation strategy in a public referral hospital in Addis Ababa, Ethiopia, based on consultation, local leadership, formal introduction, and supported supervision with subsequent audit and feedback. Planning, implementation and assessment took place from December 2011 to December 2012. The planning phase, from December 2011 until April 2012, involved a multidisciplinary consultative approach using local leaders, volunteer clinicians, and staff from non-governmental organisations, to draw up a locally agreed and appropriate Checklist. Implementation in April 2012 involved formal teaching and discussion, simulation sessions and role play, with supportive supervision following implementation. Assessment was performed using completed Checklist analysis and staff satisfaction questionnaires at one month and further Checklist analysis combined with semi-structured interviews in December 2012. Checklist compliance rates were 83% for general anaesthetics at one month after implementation, with an overall compliance rate of 65% at eight months. There was a decrease in Checklist compliance over the period of the study to less than 20% by the end of the study period. The 'Sign out' section was reported as being the most difficult section of the Checklist to complete, and was missed completely in 21% of cases. The most commonly missed single item was the team introduction at the start of each case. However, we report high staff satisfaction with the Checklist and enthusiasm for its continued use. We report a detailed implementation strategy for introducing the WHO Surgical Safety Checklist to a low-resource setting. We show that this approach can lead to high completion rates and high staff satisfaction, albeit with a drop in completion rates over time. We argue that maximal benefit of the Surgical Safety Checklist is likely to be when it engenders a conversation around patient safety within a department, and when there is local ownership of this process.
    Patient Safety in Surgery 03/2014; 8(1):16. DOI:10.1186/1754-9493-8-16
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    • "Generally, compliance rates are often found to be below 100% [8,12-14]. Health care professionals’ (HCP) knowledge also plays a crucial role for correct and compliant checklist use [7,11,15,16]. Vats et al. [13] explicitly identified lack of knowledge as one important aspect for not correctly using the checklist. The better people are educated about how and why to use the surgical checklist, the more compliant they are. "
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    ABSTRACT: The WHO-surgical checklist is strongly recommended as a highly effective yet economically simple intervention to improve patient safety. Its use and potentially influential factors were investigated as little data exist on the current situation in Switzerland. A cross-sectional online survey with members (N = 1378) of three Swiss professional associations of invasive health care professionals was conducted in German, French, and Italian. The survey assessed use of, knowledge of and satisfaction with the WHO-surgical checklist. T-Tests and ANOVA were conducted to test for differences between professional groups. Bivariate correlations were computed to test for associations between measures of knowledge and satisfaction. 1090 (79.1%) reported the use of a surgical checklist. 346 (25.1%) use the WHO-checklist, 532 (38.6%) use the Swiss Patient Safety Foundation recommendations to avoid Wrong Site Surgery, and 212 (15.7%) reported the use of other checklists. Satisfaction with checklist use was generally high (doctors: 71.9% satisfied, nurses: 60.8% satisfied) and knowledge was moderate depending on the use of the WHO-checklist. No association between measures of subjective and objective knowledge was found. Implementation of a surgical checklist remains an important task for health care institutions in Switzerland. Although checklist use is present in Switzerland on a regular basis, a substantial group of health care personnel still do not use a checklist as a routine. Influential factors and the associations among themselves need to be addressed in future studies in more detail.
    Patient Safety in Surgery 12/2013; 7(1):36. DOI:10.1186/1754-9493-7-36
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    • "These strategies may reduce the risk to breast cancer patients in our NHS Trust but are not guaranteed to have the same effect within the wider NHS and beyond. Ultimately, an adequate pre-operative safety briefing along with specialty specific modifications and an adherence to the WHO checklist [13,14] are more likely to lead to a consistent and sustainable improvement in patient safety. Regarding the latter, the WHO surgical safety checklist should be adapted for the needs of the breast cancer patient, along the lines illustrated in Table 1. "
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    ABSTRACT: The introduction of the National Health Service (NHS) Breast Screening Programme has led to a considerable increase in the detection of impalpable breast cancer. Patients with impalpable breast cancer typically undergo oncological resection facilitated either by the insertion of guide wires placed stereo-tactically or through ultra-sound guided skin markings to delineate the extent of a lesion. The need for radiological interventions on the day of surgery adds complexity and introduces the risk that a patient may accidentally transferred to the operating room directly without the image guidance procedure. A case is described of a patient who required a pre-operative ultrasound scan in order to localise an impalpable breast cancer but who was accidentally taken directly to the operating theatre (OR) and anaesthetised without pre-operative intervention. The radiologist was called to the OR and an on-table ultrasound was performed without further consequence. It is evident that breast cancer patients undergoing image-guided resection are exposed to an additional layer of clinical risks. These risks are not offset by the World Health Organisation surgical safety checklist in its present guise. Here, we review a number of simple and inexpensive changes to the system that may improve the safety of the breast cancer patient undergoing surgery.
    Patient Safety in Surgery 07/2012; 6(1):15. DOI:10.1186/1754-9493-6-15
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