surgical safety checklist: implementation in an ambulatory ...dans un centre de chirurgie...

REPORTS OF ORIGINAL INVESTIGATIONS

Surgical safety checklist: implementation in an ambulatorysurgical facility

La liste de controle de la securite chirurgicale et sa mise en œuvredans un centre de chirurgie ambulatoire

Pamela J. Morgan, MD • Lisa Cunningham, BA (Hons) • Sohini Mitra, BSc •

Natalie Wong, BHSc • Wei Wu, MSc • Victoria Noguera, RN •

Mary Li, MSc • John Semple, MD

Received: 17 September 2012 / Accepted: 6 March 2013 / Published online: 16 March 2013

� Canadian Anesthesiologists’ Society 2013

Abstract

Purpose In 2007, the World Health Organization created

a Surgical Safety Checklist (SSC) that encompassed a

simple set of surgical safety standards. The threefold pur-

pose of this study was to add ambulatory-specific items to

the SSC, to introduce the items into an ambulatory surgical

facility, and to determine if patient outcomes regarding

postoperative pain and nausea/vomiting improved follow-

ing implementation. In addition, safety attitudes, antibiotic

timing, regional anesthesia/nerve blocks, preemptive pain

medications, prophylactic antiemetics, length of stay, and

hospital admission were also assessed.

Methods After Research Ethics Board approval, staff

complete a Safety Attitudes Questionnaire. Seven items

were added to the SSC. Data were then collected on 180

surgical cases before SSC implementation and 195 cases

following implementation. Compliance with each section of

the SSC was assessed.

Results On postoperative day one, the median (97.5%

confidence interval [CI]) difference between pre- and post-

implementation pain scores was 0.5 (97.5% CI, 0 to 1;

P = 0.13), and the median difference in the rate of post-

discharge nausea/vomiting was -8.4% (97.5% CI, -17.9

to 1.1; P = 0.06). There was no improvement in safety

attitudes or any of the secondary outcomes, with the

exception of the use of preemptive pain medications.

Compliance with the three sections of the checklist, i.e.,

BRIEFING, TIME OUT, and DEBRIEFING was 99.49%,

97.95%, and 96.92%, respectively. There was low com-

pliance in verbalization of the added ‘‘ambulatory-specific

items’’.

Conclusion Potential reasons for lack of uptake and

integration include poor ‘‘user’’ buy-in, an overly lengthy

checklist, and lack of prioritization of ambulatory-specific

items. A shortened SSC was developed based on the results

of this study. This trial was registered at ClinicalTrials.gov

ID: NCT00934310.

Author contributions Pamela J. Morgan was involved in theacquisition of funding for this study. Pamela J. Morgan LisaCunningham, Wei Wu, Victoria Noguera, and John Semple wereinvolved in the conception and design of the study. LisaCunningham, Sohini Mitra, Natalie Wong, and Mary Li wereinvolved in the acquisition of data for the study. Pamela J. Morganwas involved in the interpretation of the data. Pamela J. Morgan, WeiWu, and Mary Li analyzed the data. Pamela J. Morgan, LisaCunningham, and Mary Li were involved in drafting the article.Sohini Mitra, Natalie Wong, Wei Wu, Victoria Noguera, and JohnSemple were involved in the critical revision of the article.

This article is accompanied by an editorial. Please see Can J Anesth

2013; 60: this issue.

P. J. Morgan, MD (&) � L. Cunningham, BA (Hons) �S. Mitra, BSc � N. Wong, BHSc � M. Li, MSc

Department of Anesthesia, Women’s College Hospital,

University of Toronto, 76 Grenville St., Toronto,

ON M5S 1B2, Canada

e-mail: [email protected]

W. Wu, MSc

Women’s College Research Institute,

University of Toronto, Toronto, ON, Canada

V. Noguera, RN

Department of Nursing, Women’s College Hospital,


J. Semple, MD

Department of Surgery, Women’s College Hospital,


123

Can J Anesth/J Can Anesth (2013) 60:528–538

DOI 10.1007/s12630-013-9916-8

Resume

Objectif En 2007, l’Organisation mondiale de la Sante a

cree une Liste de controle de la securite chirurgicale (LCSC)

couvrant un ensemble simple de normes de securite pour la

chirurgie. L’objectif triple de cette etude etait d’ajouter des

elements specifiques au contexte ambulatoire a la LCSC,

d’introduire ces elements dans un centre de chirurgie

ambulatoire, et de determiner si les devenirs des patients

en matiere de douleur et de nausees et vomissements

postoperatoires etaient ameliores suite a la mise en œuvre

de la LCSC. En outre, les attitudes face a la securite,

l’administration opportune des antibiotiques, l’anesthesie

regionale / blocs nerveux, les medicaments de prevention de la

douleur, les antiemetiques en prophylaxie, la duree du sejour

et les admissions a l’hopital ont egalement ete evalues.

Methode Apres avoir recu le consentement du Comite

d’ethique de la recherche, le personnel de l’etablissement a

rempli un Questionnaire sur les attitudes face a la securite,

a la suite duquel sept elements ont ete ajoutes a la LCSC.

Les donnees ont ensuite ete colligees sur la base de 180 cas

chirurgicaux avant la mise en œuvre de la LCSC et de 195

cas apres sa mise en œuvre. Le respect de chaque section

de la LCSC a ete evalue.

Resultats Au premier jour postoperatoire, la difference

mediane (intervalle de confiance [IC] 97,5 %) entre les

scores de douleur avant et apres mise en œuvre etait de 0,5

(IC 97,5 %, 0 a 1; P = 0,13), et la difference mediane dans

l’incidence de nausees et vomissements apres le conge etait

de -8,4 % (IC 97,5 %, -17,9 a 1,1; P = 0,06). Il n’y a eu

aucune amelioration dans les attitudes face a la securite ou

dans toute autre mesure secondaire, a l’exception de

l’utilisation de medicaments de prevention de la douleur. Le

respect des trois sections de la liste de controle, soit Reunion

preparatoire, Temps mort et Reunion-bilan (BRIEFING,

TIME OUT, DEBRIEFING) etait de 99,49 %, 97,95 %, et

96,92 %, respectivement. Le respect etait peu maintenu au

niveau de la verbalisation des « elements specifiques au

contexte ambulatoire » ajoutes.

Conclusion Parmi les raisons potentielles ayant freine

l’adoption et l’integration de cette liste amelioree, citons le

manque de conviction des « utilisateurs », la longueur de

la liste de controle, et le manque de priorisation des

elements specifiques au contexte ambulatoire. Une LCSC

raccourcie a ete mise au point sur la base des resultats de

cette etude. Cette etude est enregistree sous ClinicalTrials.

gov, ID: NCT00934310.

It has been more than ten years since the Institute of

Medicine published the pivotal report, To Err is Human:

Building a Safer Health System.1 The patient safety

movement has made significant strides, and the develop-

ment of the World Health Organization’s (WHO) Surgical

Safety Checklist (SSC) was the first major international

collaboration to improve perioperative patient safety. The

SSC was piloted in eight hospitals around the world from

October 2007-September 2008.2 The death rate was 1.5%

before the checklist was introduced, and the rate declined

to 0.8% afterward (P = 0.003). Furthermore, inpatient

complications occurred in 11.0% of patients at baseline and

in 7.0% of patients after the checklist was introduced

(P \ 0.001).2 Subsequent studies have supported the find-

ings in this hallmark publication.3-7

The significant improvement in morbidity and mortality was

shown in inpatient hospitals. During the past decade, however,

there has been a 300% increase in the number of surgical/

diagnostic procedures performed in ambulatory surgical cen-

tres in the United States. In ambulatory surgical centres, there is

a much lower incidence in morbidity and mortality and a dif-

ferent set of complications.8 In a report by Kurrek and Twersky,

the authors studied the literature published during 1997-2008

for incidences of mortality and morbidity in out-of-hospital

facilities.9 Their findings indicated a mortality rate of 0.00008-

0.05% and a complication rate of 0.7-1.3%.

Post-discharge nausea and vomiting (PDNV) is an impor-

tant contributor to postoperative morbidity in the ambulatory

surgical population.10 Similarly, postoperative pain is under-

managed, with as many as 86% of patients experiencing

moderate to severe pain.11 The purpose of this study was to

examine the effectiveness of the SSC in the context of an

ambulatory surgical facility by adding ambulatory care-spe-

cific items to the checklist, assessing adherence to the safety

checklist items, and examining the impact of the SSC on

safety attitudes and important patient outcomes.

Methods

After Research Ethics Board approval, all operating room and

postoperative anesthetic care unit personnel in an ambulatory

surgical facility were asked to complete a 58-item validated

Safety Attitudes Questionnaire (SAQ).12,13 Questions pertain-

ing to communication and collaboration were assessed using a

five-point scale with 1 = very low and 5 = very high, and the

individual’s ‘‘experience’’ in the work environment was

assessed using a five-point scale with 1 = disagree strongly

and 5 = agree strongly.

Champions committee and checklist development

A committee was formed comprising representatives of all

perioperative disciplines, including anesthesiology, sur-

gery, and nursing. The committee consisted of three nurse

Safety checklist in ambulatory surgery 529

123

administrators, a clinical nurse educator, eight registered

nurses (RN), four surgeons (plastics, urology, orthopedics,

and gynecology), three staff anesthesiologists, and an

anesthesia resident. The mandate of the committee was to

determine the specific items to add to the SSC that would

reflect patient outcomes in an ambulatory surgical facility

and to determine how the checklist would be implemented.

The Canadian version of the SSC (adapted from the

World Health Organization’s Surgical Safety Checklist by

the Canadian Patient Safety Institute) was downloaded

from the Canadian Patient Safety Institute Web site and

used as the preliminary template (Appendix A: reproduced

with permission) (http://signup.patientsafetyinstitute.ca/English/

toolsResources/sssl/Pages/SurgicalSafetyChecklist.aspx) This

checklist consists of 59 items. ‘‘Items’’ were defined as any

phrase preceded by either a checkbox or a dash. A litera-

ture review was then conducted to determine the most

important postoperative outcomes in the ambulatory sur-

gical population. Items related to these outcomes that had

the potential to improve postoperative morbidity and could

be added to the checklist were developed and presented to

the committee for discussion. Items were added to the

checklist if committee consensus was achieved. Seven

additions were made to the WHO SSC. In the BRIEFING

section: under ‘‘Surgeon(s) review(s)’’, i.)intraoperative

local anesthetic infiltration was added; under ‘‘Anesthesi-

ologist(s) review(s)’’, ii.)general anesthesia versus regional

anesthesia, iii.)nerve block, and iv.)intraoperative antie-

metics (as a single item) were added; and under ‘‘Special

precautions’’, v.)preemptive pain medication was added. In

the TIME OUT section, vi.)allergies was added, and in the

DEBRIEFING section, vii.) local anesthetic infiltration was

added. The added items were specifically identified by

using a red, italicized, and underlined font, and they were

indicated with an asterisk. As a result, the BRIEFING

section consisted of 41 items; the TIME OUT section

consisted of ten items, and the DEBRIEFING section

consisted of 15 items for a total of 65 items (Appendix B:

reproduced with permission). In addition, a 17-item HAND

OFF section was added; however, this section was not

verbally included in the SSC and compliance data were not

collected on this section. Rather, it was included as a

guideline that the RN could use in handing over either

during the procedure or in the postanesthetic care unit.

Data collection

A dedicated research assistant attended surgical procedures

with the principal investigator and completed the SSC data

form until the principal investigator was satisfied with the

accuracy of data collection. University students (n = 12)

were then recruited to participate as observers and data

collectors over the course of the one-year study. All students

received an introduction and explanation of the study pro-

tocol by the principal investigator and research assistant.

The research assistant accompanied each student in the

operating room until fidelity of data collection was

achieved. Students were instructed to leave the answer blank

if they weren’t able to determine the answer to a question.

Once completed, the research assistant reviewed all data

collection forms for missing data. Chart reviews were con-

ducted to fill in missing data points where possible.

Before introduction of the adapted SSC, trained person-

nel attended a random sample of ambulatory surgical

procedures and prospectively collected data. Operating

room personnel were not informed as to the specific reason

for the observer’s presence in the operating room. All

ambulatory surgical procedures were eligible for inclusion

in the study. Once data collection was completed on the

calculated sample size and following a multidisciplinary

education session, the SSC was introduced into all operating

rooms and a period of three weeks was given to allow per-

sonnel to adapt to its use. A laminated copy of the adapted

SSC was posted and available in every operating room, and

descriptors of the individual items were located on the

reverse side of the laminated SSC. The committee decided

that the surgeon would conduct the BRIEFING section, the

RN, anesthesiologist, or surgeon would conduct the TIME

OUT section, and the circulating RN would conduct the

DEBRIEFING section using the laminated SSC as a guide.

After the introductory time period, trained observers

again collected the same information as prior to SSC

implementation as well as data regarding adherence to the

three sections of the SSC (BRIEFING, TIME OUT, and

DEBRIEFING) and to the individual items within these

sections. Operating room personnel were not aware of the

specific data being collected by the observers. The data

collector checked off those items in each section that were

verbally discussed during each surgical procedure. After all

data were collected, perioperative personnel were again

asked to complete the SAQ.

The primary outcome was the incidence of pain and

nausea/vomiting on postoperative day one, which was

obtained by telephone interview. Post-discharge pain was

assessed using a scale of 1-10: 1 = no pain and 10 = the

worst possible pain. Nausea and vomiting was assessed

using a four-point scale: 0 = no nausea/vomiting,

1 = mild, 2 = moderate, 3 = severe nausea/vomiting.

Secondary outcomes included the timing of perioperative

antibiotic administration (antibiotic administration to inci-

sion time), the use of preemptive nonsteroidal anti-

inflammatory medications (yes/no), the use of prophylactic

antiemetics (yes/no), the use of regional anesthesia (yes/no),

the use of regional nerve blocks (yes/no), the length of stay

in the surgical facility, and the number of patients requiring

admission.

530 P. J. Morgan et al.

123

http://signup.patientsafetyinstitute.ca/English/toolsResources/sssl/Pages/SurgicalSafetyChecklist.aspx

http://signup.patientsafetyinstitute.ca/English/toolsResources/sssl/Pages/SurgicalSafetyChecklist.aspx

Statistical analyses

Sample size calculation

The standard deviation (SD) of postoperative pain scores

following outpatient surgery was 2.4,14 and the incidence

of postoperative nausea and vomiting (PONV) ranged from

20-30%.15 Based on this information and to detect a min-

imum difference of one point in pain score and a 15%

incidence rate, the sample size was calculated as 160 per

group with an alpha = 0.025 and power = 0.80.

Data analysis

The data were analyzed using descriptive statistics. For

continuous variables, the Shapiro-Wilk and Kolmogorov-

Smirnov tests were used to test the hypothesis of normal

distribution. Non-normally distributed data were reported

as median (interquartile range [IQR]) and were evaluated

with a Mann-Whitney U test. Categorical variables were

presented as count (percentages) and were evaluated using

Fisher’s exact test. For primary outcomes, P val-

ues \ 0.025 were regarded as significant, corresponding to

the Bonferroni correction to control the familywise error

rate at 0.05 for the two tests performed. The 97.5% con-

fidence intervals (CI) were calculated for the differences in

median and percentages. For secondary outcomes, P val-

ues \ 0.007 were regarded as significant, corresponding to

the Bonferroni correction for the seven tests performed.

The 99.3% CI of differences were calculated.

SAQ

This is a 58-item questionnaire to assess staff safety atti-

tudes, which includes an assessment of communication and

collaboration among staff. A repeated measures analysis of

variance was used to assess the results. Statistical signifi-

cance was defined as P \ 0.05.

Analyses were performed using SAS� version 9.2 (SAS

Institute, Inc., Cary, NC, USA).

Results

Pre-implementation data collection occurred over a period

of seven months and post-implementation data collection

occurred over a period of five months, for a total study

period of one year.

In the pre-implementation phase, SAQs were distributed

to 86 perioperative personnel, 70 of which were returned.

Due to the departure of a surgical program, 14 surgeons

were not present in the post-implementation phase, which

left 56 SAQs for distribution, 50 of which were completed.

The mean (SD) value for communication and collaboration

was high in both groups (mean 3.99 (0.66) and 4.09 (0.61),

respectively; P = 0.36), but there was no improvement

after implementation of the SSC. The assessment of the

staff’s ‘‘experience’’ in the working environment was also

good (mean 3.69 (0.29) and 3.76 (0.35), respectively;

P = 0.09), but again showed no statistical difference

between time periods. There was no improvement in the

six items related to teamwork and safety climate that

Haynes identified as most likely to respond to a checklist

intervention16 (Table 1).

Data on 180 patients were obtained prior to implemen-

tation of the SSC, and data on 195 patients were obtained

following implementation. There was no statistically sig-

nificant difference in age, sex, or type of surgical procedure

between the patient populations before and after SSC

implementation (Table 2). The median difference in pain

scores between groups was 0.5 (97.5% CI, 0 to 1;

P = 0.13). Since the incidence of nausea/vomiting was

Table 1 Safety Attitudes Questionnaire

Characteristics Pre (n=50) Post (n=50) P value

I would feel safe being treated here as a patient 4.44 (0.61) 4.40 (0.76) 0.3

Briefing operating room (OR) personnel before a surgical procedure is important for patient safety 4.76 (0.48) 4.79 (0.50) 0.82

I am encouraged by my colleagues to report any patient safety concerns I may have 4.24 (0.85) 4.24 (0.90) 0.99

In the ORs here, it is difficult to speak up if I perceive a problem with patient care 2.26 (1.09) 1.98 (1.03) 0.7

The physicians and nurses here work together as a well-coordinated team 4.20 (0.64) 4.30 (0.71) 0.39

Personnel frequently disregard rules or guidelines (e.g., handwashing, treatment

protocols/clinical pathways, sterile field, etc.) that are established for the OR

2.13 (1.00) 2.28 (1.22) 0.60

Total 4.22 (0.41) 4.25 (0.52) 0.71

Responses were scored on a five-point scale with 1 = strongly disagree and 5 = strongly agree. All values are mean (standard deviation). The

total value is the mean of responses, with negative statements (‘‘In the ORs here…’’ and ‘‘Personnel frequently disregard…’’) reverse-scored


123

low, comparison was made between those experiencing no

nausea/vomiting and those experiencing some nausea/

vomiting (mild, moderate, or severe). The difference in the

incidence rate of nausea/vomiting between the pre- and

post-implementation groups was -8.4% (97.5% CI, -17.9

to 1.1; P = 0.06) (Table 3).

Ninety-eight of 180 (54.4%) patients received prophy-

lactic antibiotics pre-implementation, and 105 of 195

(53.8%) patients received antibiotics post-implementation.

The antibiotics were administered after the incision to 5 of

98 (5.1%) patients pre-implementation and to 6 of 105

(5.71%) patients post-implementation (P = 0.85). The

remainder of the patients in both groups received antibi-

otics within 60 min before the incision. The median

difference in minutes in the timing of antibiotic adminis-

tration was 1 (99.3% CI, -2 to 4; P = 0.45). Before and

after implementation of the SSC, the difference in the use

of regional anesthesia was -3.4% (99.3% CI, -9.4 to 2.5;

P = 0.11), and the difference in the use of regional blocks

was 1.0% (99.3% CI, -11.5 to 13.0; P = 0.89). A higher

Table 2 Demographic data

Characteristics Before implementation

(n = 180)

After implementation

(n = 195)

Age: mean (standard deviation) 41.5 (14.3) 40.2 (13.4)

Female: n (%) 120 (67%) 135 (69%)

Procedure: n (%)

Gynecology 61 (34%) 57 (29%)

General surgery 34 (19%) 36 (18%)

Plastic surgery 18 (10%) 38 (19%)

Urology 7 (4%) 11 (6%)

Orthopedic surgery 60 (33%) 53 (27%)

Table 3 Primary outcomes

Characteristics Before

implementation

(n=180)

After

implementation

(n=195)

Difference

(97.5% confidence

interval)

P value

Pain (POD1): median [Interquartile

range] 1 = no pain; 10 = worst possible pain

3 [2-5] 3 [2-5] 0.5 (0 to 1) 0.13

Nausea and/or vomiting (POD1)

Some (mild, moderate, severe): n (%) 32 (17.8%) 51 (26.2%) -8.4% (-17.9 to 1.1) 0.06

POD = postoperative day

Table 4 Secondary outcomes

Characteristics Before

implementation

(n = 180)

After

implementation

(n = 188)

Difference

(99.3% confidence

interval)

P value

Antibiotic to incision time Minutes: median, [IQR] 10 [5-17] 10 [7-16] 1 (-2 to 4) 0.45

Preoperative NSAIDS given: n (%) 16 (8.9%) 61(32.4%) -23.3% (-35.5 to -11.1) B 0.001

Received PONV prophylaxis, n (%) 156 (86.7%) 149 (79.3%) 8.0% (-3.4 to 19.4) 0.05

Regional anesthesia n (%) 10 (5.6%) 4 (2.1%) -3.4% (-9.4 to 2.5) 0.11

Regional blocks: n (%) 32 (17.8%) 34 (18.1%) 1.0% (-11.5 to 13.0) 0.89

Length of stay in facility Hours: median, [IQR] 3.1 [2.4-3.9] 3.2 [2.6-3.9] -0.1 (-0.4 to 0.2) 0.38

Patients admitted to hospital: n (%) 1 (0.6%) 3 (1.6%) -1.1% (-4.2 to 2.1) 0.62

IQR = interquartile range; NSAIDS = nonsteroidal anti-inflammatory drugs; PONV = postoperative nausea and vomiting


123

percentage of patients received PONV prophylaxis in the

pre-implementation group than in the post-implementation

group (86.7% vs 79.3%, respectively) with a difference of

8.0% (99.3% CI, -3.4 to 19.4; P = 0.05). There was a

significant increase in the use of preemptive pain medica-

tions after implementation of the SSC (difference -23.3%;

99.3% CI, -35.5 to -1.1) (Table 4).

Items on the SSC

Compliance with the three sections on the checklist,

BRIEFING, TIME OUT, and DEBRIEFING was 99.49%,

97.95%, and 96.92% respectively. Compliance was defined

as a verbal discussion of at least one item in the section.

The median [IQR] number of items verbalized was: 19 [15-

22] items in the 41-item BRIEFING section, 5 [4-6] items

in the ten-item TIME OUT section, and 9 [7-11] items in

the 15-item DEBRIEFING section.

In the BRIEFING, TIME OUT, and DEBRIEFING

sections, there were 17, two, and two items, respectively,

that were verbalized \ 33% of times. After consensus of

the original champions’ committee members, the SSC used

in this study was adapted in the following way: 15 items

were deleted from the BRIEFING section; five items were

deleted from the TIME OUT section, and one item was

deleted from the DEBRIEFING section. This resulted in a

final 45-item checklist for use in an ambulatory surgical

centre (Figs. 1, 2). Items relating to the prevention of

postoperative pain and nausea were highlighted on the final

version by using capital letters and underlining (available

from the authors upon request).

Discussion

The purpose of this study was to adapt an already devel-

oped checklist to include items relevant to the ambulatory

surgical population. Ambulatory surgery has low rates of

major morbidity and mortality so outcomes, such as post-

operative pain and PONV or post-discharge nausea and

vomiting (PDNV), are more relevant in this population.17

There is evidence to suggest that attention to certain

measures can significantly decrease the severity of post-

operative pain and PONV/PDNV, including such

interventions as preemptive pain medications, the use of

regional anesthesia or regional nerve blocks, and the use of

prophylactic antiemetics, especially in high-risk surgical

procedures/patients.15 Despite adding items to the SSC that

pertain to these specific interventions, verbalization of

these items occurred in \ 10% of observed cases. Conse-

quently, it is not surprising that there was no improvement

in post-discharge pain and nausea/vomiting on the first

postoperative day before and after checklist introduction.

We also did not show a difference in the use of regional

anesthesia or prophylactic antiemetics. There was a sig-

nificant increase in the use of preemptive analgesics after

SSC introduction. This difference resulted from a change in

process whereby orthopedic patients began to receive

preoperative nonsteroidal medications on a routine basis

during this period of time; this change was unrelated to the

introduction of the SSC.

Checklist use has been a mainstay of safety practices in

the aviation industry for years. The use of checklists in

health care, however, has been much slower to evolve

despite evidence that their use improves patient outcomes

and/or improves team behaviours and communica-

tion.5,18-23 Specifically, use of the WHO SSC has shown a

decrease in inpatient morbidity and mortality2,4-7,24 as well

as improvement in teamwork skills, communication, and

adherence to process measures.1,23,25-27 Nevertheless, Ko

et al.’s recent systematic review of checklist use in medi-

cine has shown limited evidence of their effectiveness.28

Analysis of the studies indicated that many were of poor

quality with low levels of evidence and a high rate of bias.

In summary, the authors determined that it was not feasible

to provide an accurate summary of any trends across all

studies.

Similar to the study by Vogts and Fourcade, compliance

with BRIEFING and TIME OUT was high in our study, but

our study also showed a high compliance with the

DEBRIEFING section.29,30 The three items most com-

monly discussed were: Allergies, Site and procedure, and

ASA Class (American Society of Anesthesiologists’ class).Fig. 1 Checklist generation


123

There is, however, a need for caution when interpreting

compliance rates. Compliance is often defined as some

discussion having occurred with respect to the three sec-

tions of the SSC; however, not all items may have been

addressed within each section. Levy et al. recently reported

that individual items were either not executed as designed

or not executed at all despite the documented 100% com-

pletion of the SSC BRIEFING section.31 Therefore, some

studies report on ‘‘completeness’’ of the SSC. The evidence

suggests that rate of ‘‘completeness’’ of the SSC is sig-

nificantly lower than the rate of compliance.5,30,32 Our

study has shown that 21 items were discussed\33% of the

time.

There are a number of reports of low compliance with

healthcare checklists.33,34 In this study, several factors

may have contributed to the low compliance within

certain areas of the SSC and the failure to use the

checklist to improve the primary and secondary out-

comes. For a checklist to be effective, users at the

‘‘sharp end’’ must appreciate its value.35 If the users are

told simply that the checklist is an institutional require-

ment and they are not given or are not interested in the

rationale for its implementation, adherence to the

checklist may be suboptimal. Certainly, in the case of

the SSC, its implementation was an institutional

requirement and an institution’s adherence to the SSC

was posted on a provincial Web site with public access.

Although attempts were made to inform all stakeholders

of the process and the rationale behind the use of the

SSC, the lack of improvement suggests that the SSC was

not implemented effectively.

This particular point is reinforced by our results from

testing safety attitudes. Safety culture has been recognized

as an important strategy in the improvement of the deficits

Fig. 2 Checklist details


123

identified in healthcare safety.36 Culture has been identified

as a factor affecting absenteeism, employee turnover,

length of stay, and readmission rates. The SAQ is a vali-

dated tool designed specifically for operating room teams

and is an adaptation of the Flight Management Attitudes

Questionnaire developed for aviation teams.37 Using six

items from the SAQ, Haynes showed an improvement in

safety attitudes before and after introduction of the SSC.38

Our study did not show an improvement in safety attitudes

using these same six items, which may be accounted for by

the higher values seen in our pre-intervention group

(Table 1).

The checklist may have been too lengthy for use in an

ambulatory surgical facility where turnover pressure is

high. Limiting the length of a checklist is considered cru-

cial for its feasibility and usefulness. In the nuclear

industry, it has been stated that ‘‘…as the list of items

grows, there may be a higher probability of overlooking

any given item.’’39 Had we pilot tested the initial adapta-

tion of the checklist at an early stage, we may have been

able to identify the checklist items that were not consis-

tently noted, allowing for an initial modification and

obviating the need for a revised checklist at the end of the

study.

The Pareto principle may be employed with respect to

checklist content. It assumes that 20% of adverse events

will account for 80% of injuries, allowing tailoring of a

checklist to focus on priority areas. If potential adverse

events are not prioritized, healthcare workers may end up

addressing 80% of the adverse events that account for only

20% of the injuries.35 In this study, addition of more items

to an already lengthy checklist was likely compounding the

lack of prioritization of SSC items. Although morbidity

from post-discharge pain and nausea/vomiting occurs,

major adverse events more likely to profit from a

‘‘checklist’’ discussion would include four items: correct

patient, correct operation, correct side, and allergy identi-

fication. In fact, despite the length of the SSC used in this

study, these four ‘‘big ticket’’ items were identified in [90% of cases. All operating room staff may have clearly

understood the rationale for discussion of these items and

were therefore compliant. Other items, however, may not

have been perceived as relevant by all users and therefore

were not mentioned. Similar to the comments of Vats et al.,

some items on the SSC were simply not relevant to cases in

an ambulatory facility and were therefore ignored.33

Another potential confounding factor in the lack of

effective SSC implementation was the fact that the sur-

geons involved in the study were not all based primarily at

our centre. They would therefore have been exposed to a

different checklist at another institution and may not have

recognized the differences between their home-based hos-

pital SSC and our ambulatory facility SSC. Hierarchy may

also have played a role in that some RNs may have been

reluctant to ‘‘step in’’ if items were not mentioned by the

attending surgeon.

In summary, the SSC was not effectively implemented

in our ambulatory facility. A number of potential reasons

have been cited. Specifically, items added to the SSC in

an attempt to improve the primary outcomes of post-

discharge pain and nausea/vomiting were ineffective,

suggesting that the SSC may not be the optimal strategy

to address these issues. Due to poor compliance with the

adapted version (Appendix B) used in this study, a final

abbreviated checklist has been developed for use in an

ambulatory surgical facility and is available from the

authors.

Acknowledgments This study was funded by a grant from the

Alternate Funding Plan Innovation Fund, Ministry of Health and

Long Term Care and Department of Anesthesia, University of Tor-

onto Merit Award.

Competing interests None declared.

Appendix A

Surgical Safety Checklist


123

Appendix B

Modified Surgical Safety Checklist


123


123

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