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A ‘paperless’ wall-mounted surgical safety checklist with migrated leadership can improve compliance and team engagement
  1. Aaron Pin Chien Ong1,
  2. Daniel A Devcich1,
  3. Jacqueline Hannam1,
  4. Tracey Lee2,
  5. Alan F Merry1,2,
  6. Simon J Mitchell1,2
  1. 1Department of Anaesthesiology, The University of Auckland, Auckland, New Zealand
  2. 2Department of Anaesthesia and Perioperative Medicine, Auckland City Hospital, Auckland, New Zealand
  1. Correspondence to Associate Professor Simon J Mitchell, Department of Anaesthesiology, The University of Auckland, Private Bag 92019, Auckland 1142, New Zealand; sj.mitchell{at}


Background Outcome benefits of using the WHO Surgical Safety Checklist rely on compliance with checklist administration.

Objective To evaluate engagement of operating room (OR) subteams (anaesthesia, surgery and nursing), and compliance with administering checklist domains (Sign In, Time Out and Sign Out) and checklist items, after introducing a wall-mounted paperless checklist with migration of process leadership (Sign In, Time Out and Sign Out led by anaesthesia, surgery and nursing, respectively).

Methods This was a pre-post observational study in which 261 checklist domains in 111 operations were observed 2 months after changing the checklist administration paradigm. Compliance with administration of the checklist domains and individual checklist items was recorded, as was the number of OR subteams engaged. Comparison was made with 2013 data from the same OR suite prior to the paradigm change.

Results Data are presented as 2013 versus the present study. The Sign In, Time Out and Sign Out domains were administered in 96% vs 98% (p=0.69), 99% vs 99% (p=1.00) and 22% vs 84% (p<0.001) of cases, respectively. The percentage of relevant checklist items administered in each domain was 60% vs 92%, 84 vs 93% and 80% vs 99%, respectively (p<0.001 for all comparisons). Two-subteam (or better) engagement at Sign In (surgeons usually absent) was 40% vs 94% of cases. Three-subteam (or all staff present) engagement at Time Out and Sign Out was 15% vs 92% and 9% vs 25% of cases, respectively (p<0.001 for all comparisons).

Conclusions Improvements in team engagement and compliance with administering checklist items followed introduction of migrated leadership of checklist administration and a wall-mounted checklist. This paradigm change was relatively simple and inexpensive.

  • Checklists
  • Safety culture
  • Compliance
  • Leadership
  • Patient safety

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  • Contributors SJM, TL and DAD were responsible for study design. AO was responsible for data collection and compilation. SJM provided clinical oversight of data collection. SJM, AFM and DAD provided general oversight of the study processes. JH conducted the statistical analyses. JH and SJM wrote the initial draft of the manuscript. All authors provided critical revision of the manuscript.

  • Competing interests AFM was the anaesthesia lead in the WHO Safe Surgery Saves Lives initiative and is Chair of the Board of the Health Quality and Safety Commission New Zealand.

  • Ethics approval The University of Auckland Human Participants Ethics Committee.

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