Implementing a surgical checklist: More than checking a box

Levy, Shauna; Senter, C.E.; Hawkins, Russell B.; Zhao, Jane; Doody, K.A.; Kao, Lillian S.; Lally, Kevin P.; Tsao, KuoJen

doi:10.1016/j.surg.2012.05.034

Cited by 173 publications

(177 citation statements)

References 11 publications

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“…30 Despite the demonstrated dose-response relationship between checklist completeness and the timeliness of ABG results, overall adherence to the checklist was only fair, at 49%. Although comparable adherence rates have been reported with other checklist-based interventions, [31][32][33][34] we were surprised by the dichotomous nature of checklist use. Whereas the majority of subjects intubated in the MICU had checklists initiated (71%), adherence was much lower for subjects intubated outside of the MICU (27%).…”

Section: Post-intubation Checklist and Time Out To Expedite Mechanicasupporting

confidence: 61%

Using a Post-Intubation Checklist and Time Out to Expedite Mechanical Ventilation Monitoring: Observational Study of a Quality Improvement Intervention

et al. 2016

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BACKGROUND: Delayed mechanical ventilation monitoring may impede recognition of lifethreatening acidemia. Coordination of multidisciplinary processes can be improved by using a checklist and time-out procedure. The study objective was to evaluate process-related outcomes after implementation of a post-intubation checklist and time out. METHODS: An observational study of a 24-bed medical ICU in Philadelphia, Pennsylvania, was conducted from January to December 2011. A random sample of mechanically ventilated adults was selected from the preintervention (n ‫؍‬ 80) and post-intervention (n ‫؍‬ 144) periods. The primary outcome was the proportion of subjects with an arterial blood gas (ABG) result within 60 min of mechanical ventilation initiation. Secondary outcomes included rates of respiratory acidosis, moderate-severe acidemia (pH <7.25), checklist initiation, and project sustainability. Chi-square analysis was used to evaluate differences in outcomes between time periods. RESULTS: After the intervention, the proportion of subjects with an ABG result within 60 min increased (56% vs 37%, P ‫؍‬ .01), and time to ABG result improved (58 min vs 79 min, P ‫؍‬ .004). Adjusting for illness severity, the proportion with an ABG result within 60 min remained significantly higher in the post-intervention period (odds ratio 2.42, 95% CI 1.25-4.68, P ‫؍‬ .009). Checklist adherence was higher with ICU intubations than for intubations performed outside the ICU (71% vs 27% checklist initiation rate, P < .001). Transfer from referring institutions (23% checklist initiation rate, P ‫؍‬ .006) negatively impacted checklist use. Implementation challenges included frequent stakeholder turnover, undefined process ownership, and lack of real-time performance feedback. CONCLUSIONS: A post-intubation checklist and time out improved the timeliness of mechanical ventilation monitoring through more rapid assessment of arterial blood gases. Implementing this peri-intubation procedure may reduce the risks associated with transitioning to full mechanical ventilatory support. Optimal implementation necessitates strategies to surmount organizational and behavioral barriers to change.

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Section: Post-intubation Checklist and Time Out To Expedite Mechanicasupporting

confidence: 61%

Using a Post-Intubation Checklist and Time Out to Expedite Mechanical Ventilation Monitoring: Observational Study of a Quality Improvement Intervention

et al. 2016

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“…The mismatch of documentation and actual compliance has been established in a study by Levy and colleagues. 30 In this prospective observational study, despite 100% documented completion of the briefing phase of the SSC, they found that most tasks were not executed as designed or were not executed at all. This poor implementation fidelity may also be an issue in Calgary.…”

Section: Discussionmentioning

confidence: 88%

“…Our study found Calgary health care providers were least invested in the debriefing component of the SSC, with some providers commenting the debriefing is likely used for 15%-40% of cases. Levy and colleagues 30 noted that despite 100% documentation of SSC completion, not all components of the SSC were completed as defined. 30 Cullati and colleagues 24 found similar results in university hospitals in Switzerland.…”

Section: Discussionmentioning

confidence: 99%

“…Levy and colleagues 30 noted that despite 100% documentation of SSC completion, not all components of the SSC were completed as defined. 30 Cullati and colleagues 24 found similar results in university hospitals in Switzerland. The "briefing" and "time out" were completed 90% and 83% of the time, respectively; however the "debriefing" was completed only 47% of the time.…”

Section: Discussionmentioning

confidence: 99%

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Attitudes and beliefs about the surgical safety checklist: Just another tick box?

Dharampal

Cameron

Dixon

et al. 2016

cjs

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Background: Following a landmark study showing decreased morbidity and mortality after implementation of the surgical safety checklist (SSC), it has been widely adopted into perioperative policy. We explored the impact of attitudes and beliefs surrounding the SSC on its uptake in Calgary. Methods:We used qualitative methodology to examine factors influencing SSC use. We performed semistructured interviews based on Rogers' theory of diffusion of innovation. Purposive and snowball sampling were used to identify surgeons, anesthesiologists and operating room nurses from hospitals in Calgary. Data collection and analysis were based on grounded theory. Two individuals jointly analyzed data and achieved consensus on emerging themes.Results: Generated themes included 1) the SSC has brought organization to previous informal perioperative checks, 2) the SSC is most helpful when it is simple, and 3) the 3 current components of the checklist are redundant. The briefing was considered the most important aspect and the debriefing the least important. Initially the SSC was difficult to implement owing to a shift in time management and perioperative culture; however, it has now assimilated into perioperative routine. Finally, though most participants agreed that the SSC might avoid some delays and complications, only a few believe there have been observable improvements to morbidity and mortality. Conclusion:Although the SSC has been integrated into perioperative practice in Calgary, participants believe that previous informal checkpoints were able to circumvent most perioperative issues. Although the SSC may help with flow and equipment, participants believe it fails to show a subjective, clinically important improvement.Contexte : Après une étude charnière ayant montré une baisse de la morbidité et de la mortalité après la mise en oeuvre de la liste de contrôle de la sécurité chirurgicale, cette dernière a été largement intégrée aux politiques périopératoires. Nous avons examiné l'effet des attitudes et des croyances entourant la liste sur son adoption à Calgary.Méthodes : À l'aide d'une méthode qualitative, nous nous sommes penchés sur les facteurs influençant l'utilisation de la liste. Pour ce faire, nous avons effectué des entrevues semi-dirigées fondées sur la théorie de la diffusion de l'innovation de Rogers. Nous avons utilisé l'échantillonnage dirigé et le sondage en boule de neige pour cibler des chirurgiens, des anesthésiologistes et des membres du personnel infirmier de salle d'opération des hôpitaux de Calgary. La collecte et l'analyse des données étaient fondées sur la théorie ancrée. Deux personnes ont analysé ensemble les données et se sont entendues sur les thèmes émergents.Résultats : Voici les principales conclusions dégagées : 1) la liste a permis de structurer les contrôles périopératoires non officiels du passé, 2) la liste est surtout utile quand elle est simple et 3) les 3 composantes actuelles de la liste de contrôle sont redondantes. Le breffage était considéré comme étant l'aspect le plus important e...

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“…Despite the benefits reported, compliance with the safety checklist has been low [6] [7]. Fourcade et al reported a checklist completion rate of only 61%, while other studies have reported completion rates as low as 21% [8]- [10].…”

Section: Introductionmentioning

confidence: 98%

The World Health Organization Surgical Safety Checklist Improves Post-Operative Outcomes: A Meta-Analysis and Systematic Review

Lau¹,

Chamberlain²

2016

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Background: The incidence of in-hospital adverse events is about 10%, with a majority of these related to surgery, and nearly half considered preventable events. In attempts to improve patient safety, the World Health Organization (WHO) developed a checklist to be used at critical perioperative moments. This meta-analysis examines the impact of the WHO surgical safety checklist (SSC) on various patient outcomes. Methods: A comprehensive search of all published studies assessing the use of the WHO SSC in patients undergoing surgery was conducted. Studies using the WHO SSC in any surgical setting, with pre-implementation and post-implementation outcome data were included. The incidence of patient outcomes (total complications, surgical site infections, unplanned return to the operating room (OR) within 30 days, and overall mortality) and adherence to safety measures were analyzed. Results: 10 studies involving 51,125 patients (27,490 prior to implementation and 23,635 after implementation of the WHO SSC) were analyzed. The implementation of the WHO SSC significantly reduced the risk of total complications by 37.9%, surgical site infections by 45.5%, unplanned return to OR by 32.1%, and mortality by 15.3%. Increased adherence to safety measures including airway evaluation, use of pulse oximetry, prophylactic antibiotics when necessary, confirmation of patient name and surgical site, and sponge count was also observed. Conclusions: The use of the WHO SSC is associated with a significant reduction in post-operative complication rates and mortality. The WHO SSC is a valuable tool that should be universally implemented in all surgical centers and utilized in all surgical patients.

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Implementing a surgical checklist: More than checking a box

Cited by 173 publications

References 11 publications

Using a Post-Intubation Checklist and Time Out to Expedite Mechanical Ventilation Monitoring: Observational Study of a Quality Improvement Intervention

Using a Post-Intubation Checklist and Time Out to Expedite Mechanical Ventilation Monitoring: Observational Study of a Quality Improvement Intervention

Attitudes and beliefs about the surgical safety checklist: Just another tick box?

The World Health Organization Surgical Safety Checklist Improves Post-Operative Outcomes: A Meta-Analysis and Systematic Review

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