Effective Surgical Safety Checklist Implementation

Harvard School of Public Health, Boston, MA, USA.
Journal of the American College of Surgeons (Impact Factor: 5.12). 03/2011; 212(5):873-9. DOI: 10.1016/j.jamcollsurg.2011.01.052
Source: PubMed


Research suggests that surgical safety checklists can reduce mortality and other postoperative complications. The real world impact of surgical safety checklists on patient outcomes, however, depends on the effectiveness of hospitals' implementation processes.
We studied implementation processes in 5 Washington State hospitals by conducting semistructured interviews with implementation leaders and surgeons from September to December 2009. Interviews were transcribed, analyzed, and compared with findings from previous implementation research to identify factors that distinguish effective implementation.
Qualitative analysis suggested that effectiveness hinges on the ability of implementation leaders to persuasively explain why and adaptively show how to use the checklist. Coordinated efforts to explain why the checklist is being implemented and extensive education regarding its use resulted in buy-in among surgical staff and thorough checklist use. When implementation leaders did not explain why or show how the checklist should be used, staff neither understood the rationale behind implementation nor were they adequately prepared to use the checklist, leading to frustration, disinterest, and eventual abandonment despite a hospital-wide mandate.
The impact of surgical safety checklists on patient outcomes is likely to vary with the effectiveness of each hospital's implementation process. Further research is needed to confirm these findings and reveal additional factors supportive of checklist implementation.

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    • "In our study, participants' perceptions of risk seemed only apply to active failures and not latent conditions. Notably, physicians actively participated only in the timeout phase of the checklist as they believed that this was the phase where errors were most likely to be detected, a point highlighted in previous work[48,49]. Nevertheless, as study participants identified, communications around the checks must be meaningful and the information sought, relevant and useful . "
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    ABSTRACT: Background: Team-based group communications using checklists are widely advocated to achieve shared understandings and improve patient safety. Despite the positive effect checklists have on collaborations and reduced postoperative complications, their use has not been straightforward. Previous research has described contextual factors that impact on the implementation of checklists, however there is limited understanding of the issues that impede team participation in checklist use in surgery. The aim of this prospective study was to identify and describe factors that drive team participation in safety checks in surgery. Methods: We observed ten surgical teams and conducted 33 semi-structured interviews with 70 participants from nursing, surgery and anaesthetics, and the community. Constant comparative methods were used to analyse textual data derived from field notes and interviews. Observational and interview data were collected during 2014-15. Results: Analysis of the textual data generated from the field notes and interviews revealed the extent to which members of the surgical team participated in using the surgical safety checklist during each phase of patient care. These three categories included: 'using the checklist'; 'working independently'; and, 'communicating checks with others'. The phases in the checking process most vulnerable to information loss or omission were sign in and sign out. Conclusions: Team participation in safety checks depends on a convergence of intertwined factors; namely, team attributes, communication strategies and checking processes. A whole-of-team approach to participation in surgical safety checks is far more complex when considering the factors that drive participation. Strategies to increase participation in safety checks need to target professional communication practices and work processes such as workflow which curtail team members' ability to participate.
    No preview · Article · Dec 2016 · Patient Safety in Surgery
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    • "The effect was seen mainly in the dimensions of teamwork framework and situation awareness, with the operation room and transplantation group demonstrating the greatest increment of perception. The findings were, at least in part, compatible with previous perspective [17,18] that surgeons who were traditionally regarded as being ranked higher in the organizational hierarchy usually also had the highest level of positive perception of teamwork, communication, and collaboration, especially in the OR settings [19,20]. Once more motivated, their active participation in the improvement program would be expected to achieve high level of success in enhance patient safety, as shown by this study. "
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    ABSTRACT: Background The process involved in organ procurement and transplantation is very complex that requires multidisciplinary coordination and teamwork. To prevent error during the processes, teamwork education and training might play an important role. We wished to evaluate the efficacy of implementing a Team Resource Management (TRM) program on patient safety and the behaviors of the team members involving in the process. Methods We implemented a TRM training program for the organ procurement and transplantation team members of the National Taiwan University Hospital (NTUH), a teaching medical center in Taiwan. This 15-month intervention included TRM education and training courses for the healthcare workers, focused group skill training for the procurement and transplantation team members, video demonstration and training, and case reviews with feedbacks. Teamwork culture was evaluated and all procurement and transplantation cases were reviewed to evaluate the application of TRM skills during the actual processes. Results During the intervention period, a total of 34 staff members participated the program, and 67 cases of transplantations were performed. Teamwork framework concept was the most prominent dimension that showed improvement from the participants for training. The team members showed a variety of teamwork behaviors during the process of procurement and transplantation during the intervention period. Of note, there were two potential donors with a positive HIV result, for which the procurement processed was timely and successfully terminated by the team. None of the recipients was transplanted with an infected organ. No error in communication or patient identification was noted during review of the case records. Conclusion Implementation of a Team Resource Management program improves the teamwork culture as well as patient safety in organ procurement and transplantation.
    Full-text · Article · Aug 2014 · BMC Surgery
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    • "Introducing the WHO Surgical Safety Checklist to the clinical environment can be challenging. Published experience from high-resource settings has identified a number of strategies to aid the introduction of the Checklist into routine clinical practice [9-11]. These emphasise a supported implementation process with time taken to enlist local leaders, educate staff in the benefits of adopting the Checklist, deliver formal training, and repeatedly reinforce Checklist use during the initial phase. "
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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.
    Full-text · Article · Mar 2014 · Patient Safety in Surgery
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