Elsevier

Surgery

Volume 152, Issue 3, September 2012, Pages 331-336
Surgery

Society of University Surgeons
Implementing a surgical checklist: More than checking a box

Presented at the 7th Annual Academic Surgical Congress, February 2012, Las Vegas, NV.
https://doi.org/10.1016/j.surg.2012.05.034Get rights and content

Background

Perioperative checklists are mandated by many hospitals as determined by the reduction in morbidity and mortality seen with the use of the World Health Organization's Surgical Safety Checklist. An adapted perioperative checklist was implemented within our hospital system, and compliance with the checklist was reported to be 100%. We hypothesized that compliance does not measure the fidelity of implementation.

Methods

During a 7-week period, a prospective study was performed to evaluate the completion of all preincision components of the surgical checklist. Pediatric surgical operations were selected for direct observation. In addition, a poststudy survey was used to assess perception and understanding of the checklist process.

Results

A total of 142 pediatric surgical cases were observed. Hospital reported data demonstrated 100% compliance with the preincision phase of the checklist for these cases. None of the cases completely executed all items on the checklist, and the average number of checklist items performed in the observed cases was 4 of 13. The most commonly performed checkpoint were the confirmation of patient name and procedure (99%) and the “timeout” at the start of the checklist (97%). The rest of the checkpoints were performed in less than 60% of cases. Adherence did not increase during the observation period.

Conclusion

These data show that despite the 100% documented completion of the preincision phase of the checklist; most of the individual checkpoints are either not executed as designed or not executed at all. These findings demonstrate lack of checklist implementation fidelity, which may be a reflection a poor implementation and dissemination strategy.

Section snippets

Context

An observational study was performed at Children's Memorial Hermann Hospital (CMHH), which is a 240-bed children's hospital within the tertiary Memorial Hermann Hospital Texas Medical Center. CMHH is 1 of 11 hospitals in the Memorial Hermann Hospital system (MHHS). CMHH is a teaching hospital; in addition to attending physicians, pediatric surgery and anesthesia fellows and residents are involved in operative cases. At the time of this study, the pediatric and adult ORs were under the same

Results

During the 7-week observational period, 142 total operations were observed. All of the pediatric surgery subspecialties at CMHH were included in the study (Table II). These operations involved 19 different attending pediatric surgeons with a median of 4 cases each (range, 2–23), and 9 anesthesiology attending physicians with a median of 20 cases each (range, 2–27). Most (98%) of cases were performed in the OR, and the median case length was 45 minutes (range, 3–415).

The BSI phase of the

Discussion

Our study showed that although compliance with the perioperative checklist was documented in 100% of observed cases in the electronic medical record, adherence to individual components of the checklist was significantly less. The BSI checklist was carried out in 97% of cases, but only 4 observed cases demonstrated completion of more than 7 of 13 checkpoints (Table I). These results are consistent with other studies demonstrating variation in implementation fidelity of checklists.6, 8, 10 For

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    Citation Excerpt :

    Generally, the completion rate is calculated by dividing the number of verified elements by the total number of verifications. In another sample study, the time-out checklist was used 100% of the time and the average number of verified items was 30% (Levy et al., 2012). Research has shown that in the case of incomplete SSC executions, the otherwise expected effect of reduction in mortality due to the implementation of the checklist is not realized; moreover, the negative feedback suggests that checklists can be perceived as not entirely useful (Barberis and McNeese 2018; Walker et al. 2012).

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