Deviations* | Corresponding to item on checklist | Not corresponding to item on checklist | Not suitable for checklist |
Preoperative (n = 130) | 217 (98%) | 1 (1%) | 3 (1%) |
Informed consent procedure | 39 | – | – |
Informed consent anaesthesia | 58 | – | – |
Information | 15 | 1 | 1 |
Instructions anaesthesiologist | 6 | – | – |
Laboratory tests and blood products | 18 | – | – |
Pressure area protection protocol | 39 | – | – |
Medication (including premedication) | 42 | – | 2 |
Peroperative (n = 171) | 110 (44%) | 18 (7%) | 122 (49%) |
Logistics OR, positioning of patient | 6 | – | 7 |
Information | 25 | 1 | 2 |
Personnel | – | – | 28 |
Communication | 3 | – | 19 |
Instruments/material/equipment presence | 29 | 9 | 7 |
Instruments/material/equipment functioning | 5 | 8 | 52 |
Patient-related | – | – | 7 |
Medication | 42 | – | – |
Postoperative (n = 130) | 114 (93%) | 1 (1%) | 7 (6%) |
Operation report in medical record | 4 | – | – |
Instructions surgeon | 12 | – | – |
Instructions anaesthesiologist | 16 | – | – |
(Protocol) information | 55 | 1 | 1 |
Technical | – | – | 1 |
Patient-related | – | – | 5 |
Discharge letter/outpatient appointments | 13 | – | – |
Medication at discharge | 14 | – | – |
Total | 441 (74%) | 20 (3%) | 132 (22%) |
Percentage of matching when considering only deviations suitable for checklist use | 441/(593–132) = 96% |
*Deviations represent not adverse events but merely deviations from the optimal and/or appropriate care process and imply potential safety hazard. The outcome of the deviations was not monitored.