Table 2

Frequency of occurrence of 11 barriers with illustrative examples

BarrierCentres (out of 18)Illustrative examples
Duplication with existing checks16Checking patient identity, accounting for sponges and adverse event reporting
Poor communication between anaesthetist and surgeon10Did not always use the same document to record postoperative orders during ‘sign out’
Time consuming9Checklist too long to complete, especially when very busy (eg, emergency surgery, end of day)
Does not make sense9Staff 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 timing9Difficult to check sample labelling at the end of the procedure if the samples were sent to the pathology laboratory during surgery
Ambiguity8Did a ‘yes’ response for ‘allergies’ mean that the patient had an allergy or that the risk of allergy had been checked
Unaccounted risks7Checklist did not cover skin preparation and postoperative prevention of pain or vomiting
Oral confirmation of items6Reading out the entire list was found unnecessary
Identification of the role and responsibility of staff6Direct 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 questions5Asking the patient his or her name three times over a very short time may cause alarm
Gaming5Ticking off unchecked items at the end of the day