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Student-observed surgical safety practices across an urban regional health authority
  1. Jessica Spence1,
  2. Barb Goodwin2,
  3. Carol Enns2,
  4. Heather Dean1
  1. 1Faculty of Medicine, University of Manitoba, Winnipeg, Canada
  2. 2Faculty of Nursing, University of Manitoba, Winnipeg, Canada
  1. Correspondence to Dr Heather Dean, Faculty of Medicine, University of Manitoba, 260 Brodie, 727 McDermot Avenue, Winnipeg, Manitoba R3E 3P5, Canada; hdean{at}


Background and aim Recognising the global push for patient safety in healthcare, students in medicine and nursing participated in a project to compare surgical safety practices in the Winnipeg Regional Health Authority (WRHA) with the WHO surgical safety checklist.

Methodology Students volunteered to participate and were oriented to operating room (OR) protocol and the WHO surgical safety checklist. Over a 1-month period, 130 students visited 65 ORs across the WRHA in interprofessional pairs, and documented the surgical safety measures employed. Feedback was solicited from OR staff. Qualitative observations were obtained during two student focus groups. Regional policy documents pertaining to OR safety were reviewed.

Results The WRHA does not employ a surgical checklist, although policy mandates several practices included in the WHO document, with a student-observed adherence rate of 75–86%. Remaining checklist items are mandated by the Canadian Anaesthesia Society and Canadian Medical Protective Association. Students observed five errors in patient care with potential for injury. No adverse events resulting in patient harm occurred.

Conclusions and discussion Surgical safety practices in ORs across the WRHA are consistent with the guidelines established by the WHO in 2007, but most are not monitored or enforced. The use of a checklist in the preoperative briefing period may improve adherence to these guidelines and facilitate surgical team interaction, resulting in standardisation of practice and improvements in team communication. Student interprofessional team observers are an effective tool for monitoring safety and teamwork.

  • Surgical checklist
  • Experiential learning
  • patient safety
  • health professions education
  • surgery

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Approximately 50% of surgical complications are avoidable.1–3 To address these preventable complications, healthcare providers have taken an approach modelled after aviation safety, using written checklists and formal verbal ‘readback’ orders.4

The most widely used checklist in surgery was developed by the WHO in 2007. Stemming from the mandate of the Safe Surgery Saves Lives campaign, the checklist sought to create standards that would decrease surgical morbidity and mortality. These standards were based on a framework provided by four themes: Clean Surgery, Safe Anaesthesia, Safe Operators and Quality Assurance. Encompassing all of these themes was the vital role of communication and teamwork.5 Use of the 19-item WHO surgical checklist was shown to significantly reduce mortality and complication rates associated with surgery.6 The specific mechanism by which this occurred was unclear, as checklist implementation involved changes in not only how operating room (OR) personnel functioned as individuals, but also how they interacted as a team.

The Winnipeg Regional Health Authority (WRHA) is the organisation overseeing healthcare in the city of Winnipeg, Canada. The WRHA does not use a preoperative checklist but has developed surgical interventions and reporting policies designed to prevent incidents that may result in patient morbidity and mortality. Given that widespread evidence supports the use of surgical safety checklists,6–10 a comparison of WRHA practice with WHO checklist guidelines was designed and implemented by nursing and medicine undergraduate students at the University of Manitoba. Based on current policies, random observations of OR practice and student observer focus groups, this study will provide the basis for a discussion of the quality improvement benefits of implementation of a checklist in settings where surgical safety practices are already in place.

Materials and methods

Review of WRHA policy

Meetings with the WRHA Surgery Program Project Manager and Chief Patient Safety Officer allowed for discussion of the relationship between physicians, hospitals and the WRHA management team. Current policies related to surgical safety11–15 were reviewed and compared with the specific elements contained within the 2007 WHO checklist.

Operating room visitations

First- and second-year medical and third-year nursing students were recruited as observers. All students interested in participating received an orientation providing an overview of OR procedures and the components of the WHO surgical safety checklist. The orientations, which were conducted by Faculty of Nursing Surgery Course Leaders and the WRHA Perioperative Nurse Educator, provided students with information about standard OR practice and procedures. Students also received specific teaching about the patient safety principles and their application to surgical procedures, the development of the WHO checklist and the importance of each of its components. Based on the WHO Patient Safety Curriculum Guide for Medical Schools,16 students were taught about the common types of adverse events associated with surgical care, including poor infection control methods, inadequate patient management and the failure by healthcare providers to communicate effectively before, during and after operative procedures. Lastly, students were shown a video demonstrating correct and incorrect ways to complete the WHO surgical safety checklist.17 18

Consent forms were distributed for students choosing to participate in focus groups. Participation in OR visitations was not contingent on consent to participate in focus groups. Student groupings of a medical and nursing student were randomly assigned based on availability of students and OR preceptors.

OR visitations, during which student pairs observed and documented surgical safety practices, took place over 3 weeks in the autumn of 2009 at five sites across the WRHA. On the days in question, students attended to the main OR desks of the hospitals they were scheduled to attend at 07:00. They met with OR educators, who briefly oriented them to the site, matched up medical and nursing students, and assigned them to an OR. Students observed the first case of the day in the OR which they were attending. Cases from a mix of surgical specialties were observed and were selected if they were to take place under general anaesthetic and likely to be complete in 5 h or less. No trauma cases were observed.

The three components of the WHO checklist included sign in (preanaesthesia), time out (before skin incision) and sign out (before patient leaves OR). Each of the items was marked as complete if it was both performed and communicated to the surgical team. Students made their observations in tandem. Each interprofessional student pair submitted one form, upon which they documented both completion of WHO checklist tasks and any observations they made throughout the procedure. These were reviewed, and student-observed lapses in patient safety were labelled by investigators as errors or adverse events. Errors were defined as the failure of a planned action to be completed as intended or the use of a wrong plan to achieve an aim.19 Patient injuries resulting from medical management (rather than underlying disease) were defined as adverse events.20 Lastly, students obtained qualitative feedback regarding benefits and challenges of checklist implementation from surgical team members, including nurses, surgeons and anaesthesiologists.

Focus groups

All students who completed a consent form were eligible to participate in focus groups. Ten students were selected for each of two focus groups using a random number generator. During each focus group, moderators facilitated discussions about student observations and feedback received from OR staff. The group was polled for their agreement or disagreement with each stated observation and asked if they had a similar experience.

Discussions were recorded anonymously, and transcripts made and reviewed. Topics of discussion were identified as themes if they were mentioned in each of the two separate groups or raised more than once within a single group. Any opposing opinions from stated observations and statements were noted.


WRHA policy

Currently, WRHA policies mandate OR practices incorporated in the WHO document.11–15

Adherence to these policies is monitored through the completion of biannual audits at each of the WRHA sites. Audit reports from June/2008–2009 were reviewed for all sites visited (K Murphy, personal communication, 2010). Adherence rates were 85–100% for preoperative patient verification, 70–100% for surgical site marking and 72–100% for preoperative time out.

Elements of safe surgical practice promoted by the WHO document,6 but not specifically incorporated into WRHA policy, include safe monitoring of anaesthesia, formal recognition of and preparation for potential loss of airway or extensive blood loss, avoidance of allergic/adverse drug reactions and provision of antibiotics (where appropriate) within 60 min prior to incision. In spite of there being no specific policy about completion of these activities, they are virtually universal, in accordance with the Guidelines for the Practice of Anaesthesia published by the Canadian Anaesthesia Society (CAS).21 This is because the Canadian Medical Protective Association (CMPA), provider of medical liability insurance for Canadian physicians, has made it clear that patient harm resulting from failure to comply with these guidelines would be indefensible.22 Student observations discussed during focus groups supported this fact, as noted in the subsection ‘Student focus groups.’

Student team OR observation

Two hundred and ninety-five students volunteered to participate in the project. Eighty students consented to participate in focus groups. Of 295 students oriented to the project, 66 pairs were randomly selected to complete OR visitations. Sixty-five out of 66 pairs completed the observation of 65 cases. One of sixty-six was not completed due to last minute student illness.

The frequency of completion of each of the WHO checklist items was compiled (table 1). The four items mandated by WRHA policy were completed 75–86% of the time. Tasks completed by individual team members but not formally communicated to the entire OR team were not recorded by students.

Table 1

Operating room observation results

Specific note was made of five errors. Two of five involved circumstances where antibiotics (intended to be given) were noted perioperatively to have been forgotten. Two of five involved operations where significant blood loss was anticipated, but blood products were not verbally confirmed to be present in the OR at the time of incision. In both of these cases, blood products were required and not immediately available. One of five involved preoperative administration of antibiotics, where a patient was unintentionally given a medication to which they were documented to be allergic.

No adverse events resulting in patient injury occurred. Student observations were limited to the procedure in question and did not include postoperative outcomes.

Student focus groups

The first focus group was attended by 7/10 students selected. The second focus group was attended by 8/10 students selected. Focus groups provided qualitative information to add to the student observations. After analysis of transcripts, four themes were identified (box 1). Two additional themes, pertaining to patient safety education, will not be discussed, as they fall outside the scope of this paper. Focus-group recording and the resulting transcript were anonymous, and thus it is impossible to attribute comments to either medical or nursing students. Nonetheless, a review of transcripts failed to find any students who disagreed with the four themes identified, even when the group was specifically polled. This suggests consistency between the two trainee groups.

Box 1

Focus-group themes based on student observations

  1. Style of communication in surgical teams

    • Informality of operating room (OR) processes

    • Lack of communication between team members

    Example statements:

    Group 1: ‘I found that the OR was a lot less formal than what I had imagined it would be and that a lot of things on the checklist were happening but nobody knew about it. One of the nurses I talked to said that the checklist would facilitate communication because everything would be done in one place at one time rather than just all over the place and that that would decrease chances of mistakes.’

    •  Seven similar statements were made during the group.

    •  No opposing opinions were expressed.

    Group 2: ‘I was very startled how little explicit talk there was prior to the surgery, especially in a tertiary centre where there are a lot of medical students, residents and nursing students coming in and out. I've spent time in the OR before in a rural centre where people are literally neighbours, and there was a very explicit timeout where a lot of important stuff was addressed.’

    •  Five similar statements were made during the group.

    •  No opposing opinions were expressed.

  2. Building respect and trust

    • Belief that incorporation of formal introductions would facilitate this

    Example statements:

    Group 1: ‘The surgeon in my OR was very demanding and the nurses didn't question him a lot. I think if a checklist was standard across all of the ORs it would allow people that wouldn't normally speak up to say “hey, did he get antibiotics?”’

    •  Four similar statements were made during the group.

    •  No opposing opinions were expressed.

    Group 2: ‘I think [incorporating introductions] is a great idea. That way, everyone knows who's there and what their responsibilities are. Just simply introducing each other creates a sense of respect for every profession.’

    •  Nine similar statements were made during the group.

    •  No opposing opinions were expressed.

  3. Formal use of checklist versus Informal practice patterns

    • Perception that most components of the 2007 WHO checklist were being completed although not communicated to all team members

    Example statements:

    Group 1: ‘I think that for the most what I observed is [OR staff] are doing everything on the checklist, they're just not formally discussing it. I think that if you're going to sell it to people you need to reinforce that they're doing a really good job and that the checklist is just another tool to make sure that you don't forget.’

    •  Three similar statements were made during the group.

    •  No opposing opinions were expressed.

    Group 2: ‘[OR staff] seemed to cover everything on the checklist but they didn't do all formal checks and explicitly confirm things.’

    •  Four similar statements were made during the group.

    •  No opposing opinions were expressed.

  4. Importance of participation of all surgical team members in a preoperative discussion about WHO checklist components

    • Observation of several occasions where important safety elements were not completed at the appropriate time because of a lack of communication

    Example statements:

    Group 1: (Student 1) ‘The timeout basically consisted of one nurse sitting off to the side and filling out something and then they started the operation. After the procedure one of the surgeons asked if the patient had any allergies. That seems like something important for the surgeon to know before the procedure.’ (Student 2) ‘That was kind of like my experience. The surgeon asked halfway through the procedure if the patient had been given antibiotics.’

    •  Four similar statements were made during the group.

    •  No opposing opinions were expressed.

    Group 2: ‘The nurses went through the time-out on their own. Neither the surgeon or anaesthetist were really involved. Then, after the operation, the surgeon asked if the patient had received antibiotics. He hadn't, even though there was an order written. That seems like a simple mistake that would have been easily prevented if everyone had participated in the time-out.’

    •  Two similar statements were made during the group.

    •  No opposing opinions were expressed.


Practice within a given OR is determined by a complex relationship between WRHA management policies, individual hospitals and members of surgical teams. Although each hospital visited has varying degrees of accountability to the WRHA, all are required to comply with level 1 policy directives, including those pertaining to surgical safety.11–15 Although WRHA policies provide a guideline, what ultimately happens within a given OR is specific to the practitioners operating within it.

In spite of this, the original WHO guidelines are being followed, although not within the organised framework of a surgical checklist. Subsequently, items which may have been completed by individual OR professionals are not conveyed to all members of the surgical team. Student observers believed that, because of the busy nature of ORs, implementation of the WHO checklist would contribute to the prevention of patient safety mishaps by enabling more effective communication. Surgical team members' feedback regarding implementation of a surgical safety checklist was generally positive, although some expressed concerns that it would needlessly make explicit activities already being completed, resulting in wasted time.

Increasing literature supports the benefits of checklists and preoperative briefings in reducing surgical morbidity and mortality,6–10 though the mechanism by which this occurs remains elusive. Based on evidence from aviation safety, the use of a checklist in the OR theoretically provides: a defence strategy to prevent human errors, a memory aid to enhance task performance, a means of standardising tasks, facilitating team coordination, a means to create and maintain a safety culture in the OR, increased job satisfaction, and support and documentation of quality control measures.23 24

Evidence supporting these potential benefits is emerging. Preoperative briefings have been shown to increase team satisfaction and patient safety, while decreasing nursing staff turnover and wrong-site surgery.10 24 25 Checklist completion takes 2–6 min,9 10 25 26 and contrary to concerns regarding wasted time, anecdotal evidence suggests that they result in an overall increase in efficiency.25 More recently, this improvement has been quantified, with circulating nurses found to make fewer trips to supply areas when a briefing was in place.26

Consistent with student opinions expressed during focus groups, increasing evidence supports the use of preoperative briefings to facilitate surgical team communication, a mechanism which may underlie their proven role in reducing surgical morbidity and mortality. Using a preintervention–postintervention design, Lingard et al examined the number of communication failures taking place in the division of general surgery at a tertiary care hospital. Subsequent to implementation of a preoperative briefing tool, communication failures per procedure declined from 3.95 to 1.31 (p<0.001), and 34% of OR briefings resulted in clinical utility, including the identification of problems, resolution of critical knowledge gaps, decision-making and follow-up actions.25 Henrikson et al examined the frequency of events involving miscommunication and disruption in surgical flow during cardiac surgery. Following implementation of a preoperative briefing, there was a reduction in disruptions per case. Additionally, groups with preoperative briefings had significantly fewer miscommunication events. Though not specifically proven, team members felt that improved communication occurred as a result of the establishment of open dialogue before each case, facilitating critical thinking about potential risks, proactive behaviour to minimise them and increased team engagement in the procedure.26

Although trained in observation of the parameters of the WHO checklist, most student observers had had limited exposure to OR settings. As such, observations may not accurately reflect practices across the WRHA. Students may not have appreciated the significance of actions or inactions, or may have overestimated the implications that they had observed. Nonetheless, the ultimate role of students was to observe which elements of the WHO surgical safety checklist were being completed and document that which took place. It was the role of investigators to judge the significance of documented observations. Given the similarity in completion rates of mandated items (75–86% observed by students; 70–100% documented during WRHA audits), student observations appear to provide a reasonable estimate.

While students had little or no OR experience, the fact remains that the opinions expressed during focus groups are consistent with the emerging body of literature supporting the use of preoperative briefings. It is, of course, possible that they were influenced by information received during orientations or by the popular support for surgical safety initiatives in the media. It is also possible that OR staff altered their safety practices as a result of being observed. Finally, the lack of disagreement in focus groups may reflect group process, and a reluctance to express dissenting opinion. As a result, focus-group themes must not be relied upon too heavily. Observed facts, however, are difficult to discount, particularly when they are consistent throughout a large group of observers across several weeks and settings.

Of 65 student team observations across the WRHA, five were associated with events identified by investigators as errors. All could have been prevented had better mechanisms of communication been in place. Team acknowledgement of patient allergies and administration of antibiotics could have ensured that the appropriate drug was given within 60 min prior to incision, as has been shown to be most effective.27 Communication to all surgical team members regarding the risk of significant blood loss and confirmation of the presence of blood products in the OR could have ensured easy accessibility, rather than the need for retrieval from hospital blood services. Beyond evidence supporting improved patient outcomes and communication with the use of surgical checklists, a structural framework which proceeds only when all components are confirmed is an intuitively effective preventive measure. Additionally, given the complex relationship that a given individual working within an OR has to three authorities—the region, the hospital and their professional licensing body—standardisation of practices across the region applicable to all of those practising within it would provide clarity and consistency within the often chaotic and confusing environment of the OR.


Surgical safety policies in place across the WRHA provide ad hoc adherence to the guidelines set out by the WHO in 2007, though not all are monitored or enforced. The use of a formal checklist-based preoperative briefing to improve adherence to these structured guidelines and facilitate surgical team interaction may result in regional standardisation of practice and improvements in team communication, with resultant benefits to clinical outcomes and job satisfaction. Student interprofessional team observers are an effective tool for monitoring safety and teamwork.


The authors would like to acknowledge the following individuals for their assistance and support: R Robson, K Murphy, R Nason, B Martin, C Ateah, E Jacobsohn and L Carrothers.



  • Funding Manitoba Institute for Patient Safety; Canadian Medical Association—non-governmental advocacy organisations.

  • Competing interests None.

  • Ethics approval Ethics approval was provided by the University of Manitoba Human Research Ethics Board.

  • Provenance and peer review Not commissioned; externally peer reviewed.