Elsevier

Surgery

Volume 156, Issue 2, August 2014, Pages 336-344
Surgery

Society of University Surgeons
Multifaceted interventions improve adherence to the surgical checklist

Presented at the 9th Annual Academic Surgical Congress in San Diego, California, February 4–6, 2014.
https://doi.org/10.1016/j.surg.2014.03.032Get rights and content

Introduction

Adherence to surgical safety checklists remains challenging. Our institution demonstrated acceptable rates of checklist utilization but poor adherence to all checkpoints. We hypothesized that stepwise, multifaceted interventions would improve checklist adherence.

Methods

From 2011 to 2013, adherence to the 14-point, pre-incision checklist was assessed directly by trained observers during three, 1-year periods (baseline, observation #1, and observation #2) during which interventions were implemented. Interventions included safety workshops, customization of a stakeholder-derived checklist, and implementation of a report card system. Chi-square and Kruskal-Wallis tests were utilized.

Results

Checklist performance was assessed for 873 cases (baseline, n = 144; observation #1, n = 373; observation #2, n = 356). Total checkpoint adherence increased (from 30% to 78% to 96%; P < .001), as did cases with correct completion of all checkpoints (from 0% to 19% to 61%; P < .001). The median (interquartile range) number of checkpoints completed per case improved from 4 (3–5) to 11 (10–12) to 14 (13–14; P < .001).

Conclusion

A strategic, multifaceted approach to perioperative safety significantly improved checklist adherence over 2 years. Checklist content and process need to reflect local interests and operative flow to achieve high adherence rates. Successful checklist implementation requires efforts to change the safety culture, stakeholder buy-in, and sustained efforts over time.

Section snippets

Context

Children's Memorial Hermann Hospital (CMHH) is an academic, 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. More than 5,500 operations are performed annually. Fourteen different pediatric specialties were observed during the study period. OR personnel, such as scrub technologists and circulating nurses, are dedicated to either adult or pediatric cases and do not crossover. For each

Results

The pre-incisional checklist performance was assessed for 873 operations (baseline [2011], 144; observation #1 [2012], 373; observation #2 [2013], 356). Adherence to the checklist significantly improved after each interventional period (from 30% to 76% to 96%; P < .001; Fig 1). The different components of the interventions and their temporal relationships to improved adherence are noted in Fig 2. The percentage of operations in which all 14 checkpoints were completed increased from 0% to 19% to

Discussion

This study demonstrated that interventions targeted to improve the culture of safety, local engagement of stakeholders, and comprehension of the checklist significantly improved checklist adherence from 30% to 96% over the course of 2 years. Disseminated protocols and guidelines rarely lead to actual practice changes, and the success is dependent largely on the implementation strategies employed.4, 13 Gonzales et al13 developed a 3-part conceptual framework for translating evidence successfully

References (24)

  • A. Borchard et al.

    A systematic review of the effectiveness, compliance, and critical factors for implementation of safety checklists in surgery

    Ann Surg

    (2012)
  • A.C. Edmondson et al.

    Disrupted routines: team learning and new technology implementation in hospitals

    Adm Sci Q

    (2001)
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