Frequency of occurrence of 11 barriers with illustrative examples
| Barrier | Centres (out of 18) | Illustrative examples |
| Duplication with existing checks | 16 | Checking patient identity, accounting for sponges and adverse event reporting |
| Poor communication between anaesthetist and surgeon | 10 | Did not always use the same document to record postoperative orders during ‘sign out’ |
| Time consuming | 9 | Checklist too long to complete, especially when very busy (eg, emergency surgery, end of day) |
| Does not make sense | 9 | Staff in some operating rooms are not accustomed to count needles and this may not even be possible after disposal into appropriate containers during surgery to avoid injury |
| Inappropriate timing | 9 | Difficult to check sample labelling at the end of the procedure if the samples were sent to the pathology laboratory during surgery |
| Ambiguity | 8 | Did a ‘yes’ response for ‘allergies’ mean that the patient had an allergy or that the risk of allergy had been checked |
| Unaccounted risks | 7 | Checklist did not cover skin preparation and postoperative prevention of pain or vomiting |
| Oral confirmation of items | 6 | Reading out the entire list was found unnecessary |
| Identification of the role and responsibility of staff | 6 | Direct observation had difficulty in identifying the person implementing the checklist during emergency and/or short procedures as all staff were totally engrossed in their task |
| Patients' attitude to questions | 5 | Asking the patient his or her name three times over a very short time may cause alarm |
| Gaming | 5 | Ticking off unchecked items at the end of the day |