ORIGINAL ARTICLE
Operating Room Clinicians’ Attitudes and Perceptions of a Pediatric Surgical Safety Checklist at 1 Institution Elizabeth K. Norton, MS, RN, CNOR,* Sara J. Singer, MBA, PhD,†‡ William Sparks, MD,§ Al Ozonoff, PhD,k¶ Jessica Baxter, RN, BSN,* and Shawn Rangel, MD, MSCE# Background: Despite mounting evidence that use of surgical checklists improves patient morbidity and mortality, compliance among surgical teams in executing required elements of checklists has been low. Recognizing that clinicians’ receptivity is a major determinant of checklist use, we conducted a survey to investigate how mandated use of a surgical checklist impacts its operating room clinicians’ attitudes about and perceptions of operating room safety, efficiency, teamwork, and prevention of medical errors. Methods: Operating room clinicians at 1 pediatric hospital were surveyed on their attitudes and perception of the novel Pediatric Surgical Safety Checklist and the impact the checklist had on efficiency, teamwork, and prevention of medical errors 1 year after its implementation. The survey responses were compared and classified by multidisciplinary perioperative clinical staff. Results: Most responses reflected positive attitudes toward checklist use. The respondents felt that the checklist reduced complications and errors and improved patient safety, communication among team members, teamwork in complex procedures, and efficiency in the operating room. Many operating room staff also reported that checklist use had prevented or averted an error or a complication. Perceptions varied according to perioperative clinical discipline, reflecting differences in perspectives. For example, the nurses perceived a higher rate of consent-related errors and site marking errors than did the physicians; the surgeons reported more antibiotic timing and equipment errors than did others. Conclusions: The surgical staff at 1 pediatric hospital who responded viewed the novel Pediatric Surgical Safety Checklist as potentially beneficial to operative patient safety by improving teamwork and communication, reducing errors, and improving efficiency. Responses varied by discipline, indicating that team members view the checklist from different perspectives. Key Words: pediatric surgical safety checklist, attitudes, perceptions, teamwork, communication, operating room, survey (J Patient Saf 2016;12: 44–50)
BACKGROUND According to the Institute of Medicine, lack of teamwork has been cited as a major reason for poor patient outcomes.1 To address team communication and the pressing demand to improve patient safety and quality in operating rooms, surgical safety checklists have been introduced. Moreover, research shows that consistent use of surgical checklists can save lives.2–4 However, effectively implementing safety checklists and ensuring compliance within operating rooms present major challenges without the structure From the Departments of *Nursing and #General Surgery, Boston Children’s Hospital; †Department of Health Policy and Management, Harvard School of Public Health; ‡Department of Medicine, Harvard Medical School/Mongan \Institute for Health Policy, Massachusetts General Hospital; §Anesthesiology and Perioperative Pain Management, and ∥Design and Analysis Core, Clinical Research Center, Boston Children’s Hospital; and ¶Department of Pediatrics, Harvard Medical School, Boston, Massachusetts. Correspondence: Elizabeth K. Norton, MS, RN, CNOR, Boston Children’s Hospital, 300 Longwood Ave, Boston, MA 02115 (e‐mail: [email protected]). The authors disclose no conflict of interest. Copyright © 2014 by Wolters Kluwer Health, Inc. All rights reserved.
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of controlled research conditions. Despite efforts to comply with mandatory rules from accrediting organizations and local regulatory bodies to prevent surgical errors and complications, officials estimate that wrong-site surgery alone occurs 40 times a week in U.S. hospitals and clinics.5 Many institutions have failed to implement a surgical safety checklist effectively because of institutional resistance and poor interdisciplinary communication.6 The World Health Organization (WHO) developed a surgical safety checklist that expanded on the universal protocol used in the operating room in an effort to improve team communication at 3 specific pause points. In 2009, a WHO international study of hospitals that had implemented the checklist reported a decline in the inpatient mortality rate from 0.9% to 0.6% and a statistically significant decline in postoperative complication rates from 10.3% to 7.1%.3 Since the WHO study, more than 4120 hospitals in 122 countries representing more than 90% of the world's population have adopted the surgical checklist.7 Several studies within the United States have reported results similar to the WHO's data, and evidence is mounting that use of a safety checklist decreases patient morbidity and mortality.2,4 However, the perceived impact of a safety checklist among multidisciplinary clinicians is relatively unknown. In 2009, one pediatric academic medical center in the Northeast responded to these national studies by developing a novel operative checklist with a pediatric focus, termed the Pediatric Surgical Safety Checklist, and implementing its use in its main campus and satellites.8 The checklist for pediatrics was modeled after the WHO checklist and adapted to meet the needs of children. One year later, a multidisciplinary team representing surgery, nursing, and anesthesia developed a survey to measure clinicians’ attitudes and perceptions regarding the impact of the checklist in the operating room. The goals of the survey were to investigate staff's attitudes toward the checklist’s content and measure the potential impact of this novel checklist on staff members’ perception of its effect on efficiency, teamwork, communication, and prevention of medical errors.
METHODS In developing the survey, the team consulted previously validated instruments. Several of the survey questions in the final instrument were modeled on the validated Safety Attitudes Questionnaire used to establish benchmarking data on the climate of patient safety in hospitals.9 The group also developed new items in consultation with a survey methodologist at the hospital and a research team from the Harvard School of Public Health led by Atul Gawande, MD, associate professor in the Department of Health Policy and Management, Harvard School of Public Health (Table 1).
Exclusion This study excluded surgical and anesthesia residents, fellows, and traveling nurses because they had significantly less exposure to the checklist than staff in more permanent positions. Survey directions clearly stated that respondents would remain anonymous. J Patient Saf • Volume 12, Number 1, March 2016
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J Patient Saf • Volume 12, Number 1, March 2016
Pediatric Surgical Safety Checklist
TABLE 1. Survey Questions Survey Questions
Answer Choices
Please indicate your role on the perioperative team.
Since its implementation in March 2009, to what degree do you think the checklist has impacted patient safety in our perioperative environment?
By what mechanisms do you believe the checklist has improved patient safety in our OR?
Since its implementation, have you observed a situation where an error or complication was prevented when the checklist was used? On the basis of your own observations, what types of errors or complications has the checklist prevented?
In your opinion, how has the practice of team introductions affected the conduct of the operation?
How has the checklist impacted overall perioperative efficiency?
In which ways do you believe the checklist has improved efficiency?
Would you want the checklist used if your own child or a child you personally cared about were undergoing a surgical procedure? Do you think perioperative care in the OR has improved since implementation of the checklist in March 2009?
Surgeon Anesthesiologist/CRNA OR nurse Surgical scrub technician Significantly improved Moderately improved Minimally improved It has not improved safety to any degree I am unsure Reduces complications and/or errors Improves teamwork in the performance of complex procedures Improves the OR team’s effectiveness in managing unanticipated events Improves communications between team members Improves compliance with evidence-based and quality-driven process measures Yes, on more than 1 occasion Yes, on 1 occasion No I am unsure Antibiotics related Correct patient/procedure/site or side related Equipment related Consent related Site not marked Blood product related Other It has improved familiarity among members of the operative team It has helped establish an environment where all team members feel comfortable asking questions and voicing concerns regarding case-related safety issues It has helped “set the tone” for improved communication and teamwork through the remainder of the case It has not made a difference It has negatively affected the conduct within the OR I am unsure Significantly improved Moderately improved Minimally improved No improvement The checklist has reduced efficiency I am unsure Reduces waste: fewer occasions of incorrect equipment sterilized or disposable supplies opened Reduces time: fewer trips out of the OR to get additional or correct equipment and/or supplies Other Yes—for any case Yes, but only for certain cases and not others No, not for any case I am unsure Yes No I am unsure
OR, operating room.
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Measure
Analysis Plan
The final survey was distributed by e-mail in August 2011 using SurveyMonkey. A total of 396 invitations were sent out to staff, and the survey was redistributed 3 times at consecutive 1-week intervals to those who had not responded. The study sample consisted of 196 (49%) multidisciplinary operating room clinicians at an academic teaching hospital's main campus and satellites, including all attending surgeons, attending anesthesiologists, certified nurse anesthetists (CRNAs), registered operating room nurses (RNs), and surgical scrub technologists (SSTs). Most of the hospital's surgical staff members are experienced across all disciplines and have practiced at this academic teaching hospital for many years with exposure to multiple patient safety efforts.
Using frequencies and percentages, the study team summarized responses first for the entire sample and then by each discipline of clinical staff (attending surgeon, attending anesthesiologist, CRNAs, RNs, and SSTs). Because the goal of this survey was descriptive and not inferential, significance testing to compare proportions or frequencies across professional discipline categories was not performed. Survey data were analyzed using the Statistical Package for the Social Sciences version 18. Approval by the hospital's internal research review board was deemed unnecessary because the survey did not technically fall under human subject research; the survey staff did not interact with the clinicians in person and did not collect personal health information.
TABLE 2. Respondent Characteristics Characteristic Job status Full time Part time Total Usual shift Day Evening Night Variable Total Majority site Site 1 Site 2 Site 3 Total Years of OR experience 1–5 6–10 11–20 ≥21 Total Years since training ended 1–5 6–10 11–20 ≥21 Total Sex Male Female Total Years at institution 1–5 6–10 11–20 ≥21 Total
Surgeon n = 49
Anesthesiologist CRNA n = 40
N/A
N/A
RN/SST n = 107 74 (70%) 31 (30%) 105 (100%)
N/A
N/A 93 (80%) 5 (5%) 2 (2%) 5 (5%) 105 (100%)
N/A
N/A 84 (80%) 11 (11%) 10 (10%) 105 (100%)
N/A
N/A 11 (11%) 18 (17%) 16 (15%) 60 (57%) 105 (100%) N/A
11 (23%) 9 (19%) 14 (29%) 14 (29%) 48 (100%)
12 (30%) 10 (25%) 9 (23%) 9 (23%) 40 (100%)
33 (69%) 15 (31%) 48 (100%)
16 (40%) 24 (60%) 40 (100%)
7 (7%) 98 (93%) 105 (100%)
15 (31%) 10 (21%) 15 (31%) 8 (17%) 48 (100%)
17 (43%) 6 (15%) 12 (30%) 5 (13%) 40 (100%)
27 (26%) 27 (26%) 18 (17%) 33 (31%) 105 (100%)
Variables are reported as number (percentage). Totals exclude missing data. Percentages may not add to 100% because of rounding. N/A, not applicable; OR, operating room.
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J Patient Saf • Volume 12, Number 1, March 2016
RESULTS Respondent Characteristics Fifty-nine percent of the respondents included RNs and SSTs; 54%, attending anesthesiologists and CRNAs; and 35%, attending surgeons (Table 2).
Improved Patient Safety/Type of Error Prevented The survey included several questions about the surgical staff's perceptions of patient safety and the type of error prevented (Table 3).
Efficiency On the basis of the theory that improved teamwork and communication may translate into improved overall efficiency, the survey queried the respondents on how the checklist has impacted efficiency (Table 4).
Opinions About the Pediatric Surgical Safety Checklist The respondents were asked their opinions about team introductions. In addition, the original checklist at this pediatric
Pediatric Surgical Safety Checklist
academic teaching hospital was designed as a “one-size-fits-all” approach. With the various types of surgical services and procedures scheduled on a daily basis, the study team aimed to determine the staff's attitudes about the relevance of the checklist content to most of the cases performed at the hospital (Table 5).
DISCUSSION Successful implementation of a surgical safety checklist outside the structure of research protocols is dependent in part on the attitudes and perceptions toward checklist use of operating room clinicians. To date, clinicians’ attitudes toward checklist use have received little attention, reflecting a gap in the literature. Studying surgical staff perceptions about the checklist is an important way to identify opportunities, to address compliance issues, and to improve the content of the checklist. The results suggest that surgical staff members generally feel that the checklist is benefiting safety in the operating room and support its use. Most of the staff members responded that the checklist improved patient safety and prevented errors. One-third of all respondents reported observing a situation in which the checklist actually prevented an error or complication. Medical errors can lead to serious complications if not detected. Thus, averting a near miss means preventing a potentially significant or even catastrophic problem.10 Staff members
TABLE 3. Improved Patient Safety/Type of Error Prevented: The Survey Included Several Questions About Surgical Staff's Perceptions of Patient Safety and the Type of Error Prevented
Question To what degree do you think the checklist has impacted patient safety in our perioperative environment? Some improvement (significant/moderate/minimal) Not improved/unsure Total* By what mechanisms has the checklist improved patient safety? (If positive response to above, check all that apply) Improves communications between team members Improves teamwork in complex procedures Reduced complications and errors Improves compliance with evidence-based and quality process measures Improves OR team’s effectiveness in managing unanticipated events Total† Have you observed a situation where an error or complication was prevented? Yes—on 1 or more occasions No/unsure Total* Types of errors or complications the checklist has prevented (If positive response to above, check all that apply) Consent related Antibiotic Correct patient/site/side/procedure Equipment related Site marking Blood product Total†
Surgeon n = 49
Anesthesiologist/CRNA n = 40
RN/SST n = 107
All N = 196
41 (85%) 7 (15%) 48 (100%)
36 (90%) 4 (10%) 40 (100%)
93 (89%) 11 (11%) 104 (100%)
170 (89%) 22 (11%) 192 (100%)
34 (79%) 27 (63%) 18 (42%) 14 (33%)
32 (89%) 24 (67%) 21 (58%) 12 (33%)
80 (83%) 54 (56%) 51 (53%) 35 (36%)
146 (83%) 105 (60%) 90 (51%) 80 (46%)
8 (19%) 43 (100%)
10 (28%) 36 (100%)
27 (28%) 96 (100%)
45 (26%) 175 (100%)
15 (31%) 33 (69%) 48 (100%)
10 (25%) 30 (75%) 40 (100%)
43 (42%) 60 (58%) 103 (100%)
68 (36%) 123 (64%) 191 (100%)
9 (60%) 11 (73%) 3 (20%) 8 (53%) 2 (13%) 1 (7%) 15 (100%)
5 (50%) 5 (50%) 5 (50%) 1 (10%) 0 (0%) 0 (0%) 10 (100%)
30 (70%) 20 (47%) 24 (56%) 20 (47%) 17 (40%) 3 (7%) 43 (100%)
44 (65%) 36 (53%) 32 (47%) 29 (43%) 19 (28%) 4 (6%) 68 (100%)
*
Total excludes missing or invalid responses. Total excludes respondents who were skipped because of branching logic.
†
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TABLE 4. Survey Response by Professional Discipline—Efficiency Questions Question
Surgeon n = 49 Anesthesiologist/CRNA n = 40 RN/SST n = 107 All N = 196
How has the checklist impacted overall OR efficiency? Some improvement (significant/moderate/minimal) None/reduced/unsure Total* In what ways has the checklist improved efficiency? (If positive response to above, check all that apply) Improves case flow Reduces waste Reduces overall case duration Total†
28 (60%) 19 (40%) 47 (100%)
24 (60%) 16 (40%) 40 (100%)
75 (74%) 27 (26%) 102 (100%)
127 (67%) 62 (33%) 189 (100%)
18 (64%) 4 (14%) 4 (14%) 28 (100%)
19 (79%) 6 (25%) 2 (8%) 24 (100%)
58 (71%) 23 (31%) 8 (11%) 75 (100%)
95 (75%) 33 (26%) 14 (11%) 127 (100%)
*
Total excludes missing or invalid responses. Total excludes respondents who were skipped because of branching logic.
†
may hesitate to admit a near miss or have different definitions of types of errors or complications to report.10 For example, problems that did not reach the patient may not be considered error averted or inefficiency and therefore go unreported. Perceptions varied across disciplines, indicating different points of view. Most of the respondents replied that the checklist had a positive impact on efficiency, including preventing delays and improving flow in the operating room. These results contrast with anecdotal reports that use of a checklist adds time to each case and negatively impacts efficiency. They also provide evidence for addressing skeptics. Efficiencies associated with checklist use may stem from better case preparation before and during the procedure that facilitates smooth operations. Despite initial concern among some professionals that staff introductions were unnecessary or a waste of time, the findings suggest that most supported the introductions, agreeing that these improved familiarity, helped establish a comfortable environment, and set the tone for improved communication and teamwork throughout the case. The literature also supports the use of team introductions. Studies have found that failures in team communication, failure to feel empowered to speak up, and failure to ask questions have all led to sentinel events.11 The results indicated that the checklist length was satisfactory for most cases. Some respondents felt that the checklist was too long, leading to checklist overload or fatigue, and noted that some content was not relevant for every procedure, particularly “short” procedures. Standardized checklists may not be appropriate for the wide variety of surgical services and diversity of procedures performed on a daily basis. Without modifying the checklist for greater relevance, long-term success and compliance may be difficult to attain. This suggests that the more value staff members attribute to checklist content, the more satisfied they may be with its length and the more likely that they may be to comply with using the checklist. Finally, the results indicate that a majority of staff members would want the checklist used with their own child for any case or for certain cases. The responses received indicate that the staff believes that patients are safer with the current checklist than without it but that there may be room for improving the checklist, thereby adding value to current checklist content. For those who responded negatively to this question, their resistance may stem from negative or indifferent feelings toward the implementation process or a valid concern regarding the checklist. Responses to the survey varied by professional discipline. The nurses cited a higher rate of site marking or consent-related
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problems, whereas the surgeons cited a higher rate of antibiotic and equipment-related problems. The nurse respondents were nearly twice as likely as the physicians (attending anesthesiologists or attending surgeons) to report observing a prevented error or complication. In a teaching hospital, the operating room nurse is often the only team member who remains with the patient throughout the entire operative procedure, whereas both the attending surgeon and the attending anesthesiologist may not be continuously present. The nurses therefore may observe problems that the attendings do not witness. In addition, it is the nurse's responsibility to review the written consent, procedure, and site marking with the patient and family before surgery. Surgical residents or fellows may resolve errors or discrepancies identified in these activities before an attending physician observes them. On the other hand, the surgeons reported antibiotic-related errors more frequently than did other disciplines. This may reflect surgeons’ concern with compliance with Surgical Care Improvement Project measures and thus greater sensitivity to reporting delays in administering antibiotics prevented by the checklist. Such differences between disciplines make the implementation of an improvement intervention such as a safe surgery checklist a complex endeavor requiring strong leadership and a tailored approach to communicating the importance of checklist use. Communicating the problems averted by the checklist to clinicians could raise awareness and promote sustained compliance. Efficiency was also viewed differently among disciplines. The nurses more often than the physicians observed efficiency improvements due to the checklist. They also more often viewed the checklist as a vehicle to improve communication. Efficiency may be less visible to the surgeon and the anesthesiologist, who may be focused on specific procedural needs. Sharing the nurses' perspective on benefits of the checklist could be helpful in convincing surgeons and anesthesiologists that the checklist can improve efficiency. However, it may be important to find a way to visibly demonstrate these improved efficiencies to sustain checklist use. With the results of the survey, it is important to identify and comprehend why some clinicians feel that the checklist does not add value to their current practice. These concerns might present opportunity for further modification to improve the checklist or its implementation. This is a question for further research and for one-on-one discussions with individual clinicians. When an institution is committed to using a checklist, its leaders must identify and address legitimate concerns before enforcing its use. Differences in opinion regarding the types of errors averted suggest that © 2014 Wolters Kluwer Health, Inc. All rights reserved.
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J Patient Saf • Volume 12, Number 1, March 2016
Pediatric Surgical Safety Checklist
TABLE 5. Survey Response by Professional Discipline—Opinions About the Hospital's Surgical Safety Checklist
Opinions Team introductions have affected the conduct of the operation (Check all that apply) Improved familiarity Helped set tone Open environment No difference Negative impact Unsure Total Current number of items on the checklist Just right Too many Not enough Total* Would you want the checklist used on your own child undergoing surgical procedure? Any case Certain cases Not any case Unsure Total*
Surgeon n = 49
Anesthesiologist/CRNA n = 40
RN/SST n = 107
Combined N = 196
34 (71%) 30 (63%) 23 (48%) 6 (13%) 2 (4%) 2 (4%) 49 (100%)
26 (65%) 26 (65%) 15 (38%) 8 (20%) 0 (0%) 2 (5%) 40 (100%)
35 (52%) 48 (46%) 45 (43%) 11 (10%) 2 (2%) 7 (7%) 107 (100%)
115 (60%) 104 (54%) 83 (43%) 25 (13%) 4 (2%) 11 (6%) 196 (100%)
31 (66%) 16 (34%) 0 (0%) 47 (100%)
26 (67%) 12 (31%) 1 (3%) 39 (100%)
67 (66%) 32 (32%) 2 (2%) 101 (100%)
124 (66%) 60 (32%) 3 (2%) 187 (100%)
33 (73%) 5 (11%) 3 (7%) 4 (9%) 45 (100%)
30 (77%) 3 (8%) 2 (5%) 4 (10%) 39 (100%)
86 (85%) 9 (9%) 0 (0%) 6 (6%) 101 (100%)
149 (81%) 17 (9%) 5 (3%) 14 (8%) 185 (100%)
*
Total excludes missing or invalid responses.
individuals with different backgrounds and responsibilities are sensitive to different issues and bring unique perspectives to the operating room environment. These differences have the potential to threaten patient safety because surgery increasingly requires groups of individuals to work together as multidisciplinary teams rather than in separate “silos.” Effective use of the safety checklist requires entire teams to change behavior.
options, which included more positive than negative choices, may have biased the respondents toward more positive responses. The limited use of open-ended questions did not permit those with concerns to voice them fully. However, our results could be instructive as a measure of attitudes of personnel in health care facilities where the checklist was not implemented as part of an organized study. Despite these limitations, this study confirmed the belief that the staff has largely accepted the use of the checklist at this pediatric academic teaching hospital.
Limitations Our study should be viewed in the context of its limitations. One limitation of this study is the exclusion of surgical and anesthesia residents, fellows, and traveling nurses. At the time of the study, this group had limited or no exposure to the checklist in our setting, which reduced the value of their feedback. However, future research should include this perspective. Another limitation was a response rate of 49%, which presents the possibility of selection bias. The respondents to the survey were experienced with long tenure at this hospital. Their exposure to prior safety efforts suggests that they may be more accepting of the checklist than less experienced personnel. Most of the respondents had been exposed to a series of patient safety efforts since 2004. The study team believes that a highly satisfied and experienced staff with patient safety experience may be relatively more inclined to accept the implementation of a new surgical safety checklist than the general population. Further, there were no comparative prechecklist data to estimate the effect of checklist implementation before and after. Response rates were not consistent across all disciplines, leaving open the possibility that differences among disciplines were a function of different response rates rather than different attitudes. The survey was not developed with an expectation that results could be generalized or applied to a larger population. Response © 2014 Wolters Kluwer Health, Inc. All rights reserved.
CONCLUSIONS The Pediatric Surgical Safety Checklist is generally supported and thought to improve patient safety to some degree by most of the surgical staff members at the hospital in which it was implemented. Overall, the survey affirmed that the surgical staff viewed the checklist as potentially beneficial to operative patient safety by improving teamwork and communication, reducing errors, and improving efficiency to some degree. Teams that use checklists in health care do so to minimize complications or errors in treatment. Although some of the survey findings could be interpreted as negative, the study team was struck by the predominantly positive nature of the comments. Very few individuals claimed that they would not want the checklist used with their child, responded negatively, or indicated that the checklist was overbearing at times. Enthusiasm for checklist use could be enhanced in several ways. First, raising awareness about situations in which the checklist averted a potential critical event could promote overall support of the checklist. Presenting concrete data on improved efficiency directly related to the checklist is another means to gain further support from those who want more evidence on the effectiveness of the checklist. Results from in-house surveys of staff perceptions provide data on colleagues’ perceptions, which may www.journalpatientsafety.com
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also be persuasive when shared. Collecting and providing all these types of information may help maintain and sustain checklist compliance. Checklist implementation requires a culture of safety, multifaceted intervention, and education. As the checklist becomes more widely accepted and the content is revised for more relevance to specific procedures, those remaining reluctant clinicians may increasingly support and sustain its use. However, mandates or other disciplinary action may ultimately be required to engage those who resist using it. Further work is needed to refine checklist content and to determine effective strategies for implementing checklists and sustaining their effect.
7. World Health Organization. Patient safety: Surgical Safety Web Map. 2012. Available at: http://maps.cga.harvard.edu:8080/Hospital/. Accessed May 31, 2013.
REFERENCES
8. Norton EK, Rangel SJ. Implementing a pediatric surgical safety checklist in the OR and beyond. AORN J. 2010;92:61–71.
1. Institute of Medicine (U.S.). Committee on Quality of Health Care in America. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: National Academy Press; 2001.
9. Sexton JB, Helmreich RL, Neilands TB, et al. The Safety Attitudes Questionnaire: psychometric properties, benchmarking data, and emerging research. BMC Health Serv Res. 2006;6:44.
4. Neily J, Mills PD, Young-Xu Y, et al. Association between implementation of a medical team training program and surgical mortality. JAMA. 2010; 304:1693–1700. 5. Mainthia R, Lockney T, Zotov A, et al. Novel use of electronic whiteboard in the operating room increases surgical team compliance with pre-incision safety practices. Surgery. 2012;151:660–666. 6. Conley DM, Singer SJ, Edmondson L, et al. Effective surgical safety checklist implementation. J Am Coll Surg. 2011;212:873–879.
2. de Vries EN, Prins HA, Crolla RM, et al. Effect of a comprehensive surgical safety system on patient outcomes. N Engl J Med. 2010;363: 1928–1937.
10. Jeffs LP, Lingard L, Berta W, et al. Catching and correcting near misses: the collective vigilance and individual accountability trade-off. J Interprof Care. 2012;26:121–126.
3. Haynes AB, Weiser TG, Berry WR, et al. A surgical safety checklist to reduce morbidity and mortality in a global population. N Engl J Med. 2009; 360:491–499.
11. Lingard L, Espin S, Whyte S, et al. Communication failures in the operating room: an observational classification of recurrent types and effects. Qual Saf Health Care. 2004;13:330–334.
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Operating Room Clinicians’ Attitudes and Perceptions of a Pediatric Surgical Safety Checklist at 1 Institution Elizabeth K. Norton, MS, RN, CNOR,* Sara J. Singer, MBA, PhD,†‡ William Sparks, MD,§ Al Ozonoff, PhD,k¶ Jessica Baxter, RN, BSN,* and Shawn Rangel, MD, MSCE# Background: Despite mounting evidence that use of surgical checklists improves patient morbidity and mortality, compliance among surgical teams in executing required elements of checklists has been low. Recognizing that clinicians’ receptivity is a major determinant of checklist use, we conducted a survey to investigate how mandated use of a surgical checklist impacts its operating room clinicians’ attitudes about and perceptions of operating room safety, efficiency, teamwork, and prevention of medical errors. Methods: Operating room clinicians at 1 pediatric hospital were surveyed on their attitudes and perception of the novel Pediatric Surgical Safety Checklist and the impact the checklist had on efficiency, teamwork, and prevention of medical errors 1 year after its implementation. The survey responses were compared and classified by multidisciplinary perioperative clinical staff. Results: Most responses reflected positive attitudes toward checklist use. The respondents felt that the checklist reduced complications and errors and improved patient safety, communication among team members, teamwork in complex procedures, and efficiency in the operating room. Many operating room staff also reported that checklist use had prevented or averted an error or a complication. Perceptions varied according to perioperative clinical discipline, reflecting differences in perspectives. For example, the nurses perceived a higher rate of consent-related errors and site marking errors than did the physicians; the surgeons reported more antibiotic timing and equipment errors than did others. Conclusions: The surgical staff at 1 pediatric hospital who responded viewed the novel Pediatric Surgical Safety Checklist as potentially beneficial to operative patient safety by improving teamwork and communication, reducing errors, and improving efficiency. Responses varied by discipline, indicating that team members view the checklist from different perspectives. Key Words: pediatric surgical safety checklist, attitudes, perceptions, teamwork, communication, operating room, survey (J Patient Saf 2016;12: 44–50)
BACKGROUND According to the Institute of Medicine, lack of teamwork has been cited as a major reason for poor patient outcomes.1 To address team communication and the pressing demand to improve patient safety and quality in operating rooms, surgical safety checklists have been introduced. Moreover, research shows that consistent use of surgical checklists can save lives.2–4 However, effectively implementing safety checklists and ensuring compliance within operating rooms present major challenges without the structure From the Departments of *Nursing and #General Surgery, Boston Children’s Hospital; †Department of Health Policy and Management, Harvard School of Public Health; ‡Department of Medicine, Harvard Medical School/Mongan \Institute for Health Policy, Massachusetts General Hospital; §Anesthesiology and Perioperative Pain Management, and ∥Design and Analysis Core, Clinical Research Center, Boston Children’s Hospital; and ¶Department of Pediatrics, Harvard Medical School, Boston, Massachusetts. Correspondence: Elizabeth K. Norton, MS, RN, CNOR, Boston Children’s Hospital, 300 Longwood Ave, Boston, MA 02115 (e‐mail: [email protected]). The authors disclose no conflict of interest. Copyright © 2014 by Wolters Kluwer Health, Inc. All rights reserved.
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of controlled research conditions. Despite efforts to comply with mandatory rules from accrediting organizations and local regulatory bodies to prevent surgical errors and complications, officials estimate that wrong-site surgery alone occurs 40 times a week in U.S. hospitals and clinics.5 Many institutions have failed to implement a surgical safety checklist effectively because of institutional resistance and poor interdisciplinary communication.6 The World Health Organization (WHO) developed a surgical safety checklist that expanded on the universal protocol used in the operating room in an effort to improve team communication at 3 specific pause points. In 2009, a WHO international study of hospitals that had implemented the checklist reported a decline in the inpatient mortality rate from 0.9% to 0.6% and a statistically significant decline in postoperative complication rates from 10.3% to 7.1%.3 Since the WHO study, more than 4120 hospitals in 122 countries representing more than 90% of the world's population have adopted the surgical checklist.7 Several studies within the United States have reported results similar to the WHO's data, and evidence is mounting that use of a safety checklist decreases patient morbidity and mortality.2,4 However, the perceived impact of a safety checklist among multidisciplinary clinicians is relatively unknown. In 2009, one pediatric academic medical center in the Northeast responded to these national studies by developing a novel operative checklist with a pediatric focus, termed the Pediatric Surgical Safety Checklist, and implementing its use in its main campus and satellites.8 The checklist for pediatrics was modeled after the WHO checklist and adapted to meet the needs of children. One year later, a multidisciplinary team representing surgery, nursing, and anesthesia developed a survey to measure clinicians’ attitudes and perceptions regarding the impact of the checklist in the operating room. The goals of the survey were to investigate staff's attitudes toward the checklist’s content and measure the potential impact of this novel checklist on staff members’ perception of its effect on efficiency, teamwork, communication, and prevention of medical errors.
METHODS In developing the survey, the team consulted previously validated instruments. Several of the survey questions in the final instrument were modeled on the validated Safety Attitudes Questionnaire used to establish benchmarking data on the climate of patient safety in hospitals.9 The group also developed new items in consultation with a survey methodologist at the hospital and a research team from the Harvard School of Public Health led by Atul Gawande, MD, associate professor in the Department of Health Policy and Management, Harvard School of Public Health (Table 1).
Exclusion This study excluded surgical and anesthesia residents, fellows, and traveling nurses because they had significantly less exposure to the checklist than staff in more permanent positions. Survey directions clearly stated that respondents would remain anonymous. J Patient Saf • Volume 12, Number 1, March 2016
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J Patient Saf • Volume 12, Number 1, March 2016
Pediatric Surgical Safety Checklist
TABLE 1. Survey Questions Survey Questions
Answer Choices
Please indicate your role on the perioperative team.
Since its implementation in March 2009, to what degree do you think the checklist has impacted patient safety in our perioperative environment?
By what mechanisms do you believe the checklist has improved patient safety in our OR?
Since its implementation, have you observed a situation where an error or complication was prevented when the checklist was used? On the basis of your own observations, what types of errors or complications has the checklist prevented?
In your opinion, how has the practice of team introductions affected the conduct of the operation?
How has the checklist impacted overall perioperative efficiency?
In which ways do you believe the checklist has improved efficiency?
Would you want the checklist used if your own child or a child you personally cared about were undergoing a surgical procedure? Do you think perioperative care in the OR has improved since implementation of the checklist in March 2009?
Surgeon Anesthesiologist/CRNA OR nurse Surgical scrub technician Significantly improved Moderately improved Minimally improved It has not improved safety to any degree I am unsure Reduces complications and/or errors Improves teamwork in the performance of complex procedures Improves the OR team’s effectiveness in managing unanticipated events Improves communications between team members Improves compliance with evidence-based and quality-driven process measures Yes, on more than 1 occasion Yes, on 1 occasion No I am unsure Antibiotics related Correct patient/procedure/site or side related Equipment related Consent related Site not marked Blood product related Other It has improved familiarity among members of the operative team It has helped establish an environment where all team members feel comfortable asking questions and voicing concerns regarding case-related safety issues It has helped “set the tone” for improved communication and teamwork through the remainder of the case It has not made a difference It has negatively affected the conduct within the OR I am unsure Significantly improved Moderately improved Minimally improved No improvement The checklist has reduced efficiency I am unsure Reduces waste: fewer occasions of incorrect equipment sterilized or disposable supplies opened Reduces time: fewer trips out of the OR to get additional or correct equipment and/or supplies Other Yes—for any case Yes, but only for certain cases and not others No, not for any case I am unsure Yes No I am unsure
OR, operating room.
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Measure
Analysis Plan
The final survey was distributed by e-mail in August 2011 using SurveyMonkey. A total of 396 invitations were sent out to staff, and the survey was redistributed 3 times at consecutive 1-week intervals to those who had not responded. The study sample consisted of 196 (49%) multidisciplinary operating room clinicians at an academic teaching hospital's main campus and satellites, including all attending surgeons, attending anesthesiologists, certified nurse anesthetists (CRNAs), registered operating room nurses (RNs), and surgical scrub technologists (SSTs). Most of the hospital's surgical staff members are experienced across all disciplines and have practiced at this academic teaching hospital for many years with exposure to multiple patient safety efforts.
Using frequencies and percentages, the study team summarized responses first for the entire sample and then by each discipline of clinical staff (attending surgeon, attending anesthesiologist, CRNAs, RNs, and SSTs). Because the goal of this survey was descriptive and not inferential, significance testing to compare proportions or frequencies across professional discipline categories was not performed. Survey data were analyzed using the Statistical Package for the Social Sciences version 18. Approval by the hospital's internal research review board was deemed unnecessary because the survey did not technically fall under human subject research; the survey staff did not interact with the clinicians in person and did not collect personal health information.
TABLE 2. Respondent Characteristics Characteristic Job status Full time Part time Total Usual shift Day Evening Night Variable Total Majority site Site 1 Site 2 Site 3 Total Years of OR experience 1–5 6–10 11–20 ≥21 Total Years since training ended 1–5 6–10 11–20 ≥21 Total Sex Male Female Total Years at institution 1–5 6–10 11–20 ≥21 Total
Surgeon n = 49
Anesthesiologist CRNA n = 40
N/A
N/A
RN/SST n = 107 74 (70%) 31 (30%) 105 (100%)
N/A
N/A 93 (80%) 5 (5%) 2 (2%) 5 (5%) 105 (100%)
N/A
N/A 84 (80%) 11 (11%) 10 (10%) 105 (100%)
N/A
N/A 11 (11%) 18 (17%) 16 (15%) 60 (57%) 105 (100%) N/A
11 (23%) 9 (19%) 14 (29%) 14 (29%) 48 (100%)
12 (30%) 10 (25%) 9 (23%) 9 (23%) 40 (100%)
33 (69%) 15 (31%) 48 (100%)
16 (40%) 24 (60%) 40 (100%)
7 (7%) 98 (93%) 105 (100%)
15 (31%) 10 (21%) 15 (31%) 8 (17%) 48 (100%)
17 (43%) 6 (15%) 12 (30%) 5 (13%) 40 (100%)
27 (26%) 27 (26%) 18 (17%) 33 (31%) 105 (100%)
Variables are reported as number (percentage). Totals exclude missing data. Percentages may not add to 100% because of rounding. N/A, not applicable; OR, operating room.
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J Patient Saf • Volume 12, Number 1, March 2016
RESULTS Respondent Characteristics Fifty-nine percent of the respondents included RNs and SSTs; 54%, attending anesthesiologists and CRNAs; and 35%, attending surgeons (Table 2).
Improved Patient Safety/Type of Error Prevented The survey included several questions about the surgical staff's perceptions of patient safety and the type of error prevented (Table 3).
Efficiency On the basis of the theory that improved teamwork and communication may translate into improved overall efficiency, the survey queried the respondents on how the checklist has impacted efficiency (Table 4).
Opinions About the Pediatric Surgical Safety Checklist The respondents were asked their opinions about team introductions. In addition, the original checklist at this pediatric
Pediatric Surgical Safety Checklist
academic teaching hospital was designed as a “one-size-fits-all” approach. With the various types of surgical services and procedures scheduled on a daily basis, the study team aimed to determine the staff's attitudes about the relevance of the checklist content to most of the cases performed at the hospital (Table 5).
DISCUSSION Successful implementation of a surgical safety checklist outside the structure of research protocols is dependent in part on the attitudes and perceptions toward checklist use of operating room clinicians. To date, clinicians’ attitudes toward checklist use have received little attention, reflecting a gap in the literature. Studying surgical staff perceptions about the checklist is an important way to identify opportunities, to address compliance issues, and to improve the content of the checklist. The results suggest that surgical staff members generally feel that the checklist is benefiting safety in the operating room and support its use. Most of the staff members responded that the checklist improved patient safety and prevented errors. One-third of all respondents reported observing a situation in which the checklist actually prevented an error or complication. Medical errors can lead to serious complications if not detected. Thus, averting a near miss means preventing a potentially significant or even catastrophic problem.10 Staff members
TABLE 3. Improved Patient Safety/Type of Error Prevented: The Survey Included Several Questions About Surgical Staff's Perceptions of Patient Safety and the Type of Error Prevented
Question To what degree do you think the checklist has impacted patient safety in our perioperative environment? Some improvement (significant/moderate/minimal) Not improved/unsure Total* By what mechanisms has the checklist improved patient safety? (If positive response to above, check all that apply) Improves communications between team members Improves teamwork in complex procedures Reduced complications and errors Improves compliance with evidence-based and quality process measures Improves OR team’s effectiveness in managing unanticipated events Total† Have you observed a situation where an error or complication was prevented? Yes—on 1 or more occasions No/unsure Total* Types of errors or complications the checklist has prevented (If positive response to above, check all that apply) Consent related Antibiotic Correct patient/site/side/procedure Equipment related Site marking Blood product Total†
Surgeon n = 49
Anesthesiologist/CRNA n = 40
RN/SST n = 107
All N = 196
41 (85%) 7 (15%) 48 (100%)
36 (90%) 4 (10%) 40 (100%)
93 (89%) 11 (11%) 104 (100%)
170 (89%) 22 (11%) 192 (100%)
34 (79%) 27 (63%) 18 (42%) 14 (33%)
32 (89%) 24 (67%) 21 (58%) 12 (33%)
80 (83%) 54 (56%) 51 (53%) 35 (36%)
146 (83%) 105 (60%) 90 (51%) 80 (46%)
8 (19%) 43 (100%)
10 (28%) 36 (100%)
27 (28%) 96 (100%)
45 (26%) 175 (100%)
15 (31%) 33 (69%) 48 (100%)
10 (25%) 30 (75%) 40 (100%)
43 (42%) 60 (58%) 103 (100%)
68 (36%) 123 (64%) 191 (100%)
9 (60%) 11 (73%) 3 (20%) 8 (53%) 2 (13%) 1 (7%) 15 (100%)
5 (50%) 5 (50%) 5 (50%) 1 (10%) 0 (0%) 0 (0%) 10 (100%)
30 (70%) 20 (47%) 24 (56%) 20 (47%) 17 (40%) 3 (7%) 43 (100%)
44 (65%) 36 (53%) 32 (47%) 29 (43%) 19 (28%) 4 (6%) 68 (100%)
*
Total excludes missing or invalid responses. Total excludes respondents who were skipped because of branching logic.
†
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TABLE 4. Survey Response by Professional Discipline—Efficiency Questions Question
Surgeon n = 49 Anesthesiologist/CRNA n = 40 RN/SST n = 107 All N = 196
How has the checklist impacted overall OR efficiency? Some improvement (significant/moderate/minimal) None/reduced/unsure Total* In what ways has the checklist improved efficiency? (If positive response to above, check all that apply) Improves case flow Reduces waste Reduces overall case duration Total†
28 (60%) 19 (40%) 47 (100%)
24 (60%) 16 (40%) 40 (100%)
75 (74%) 27 (26%) 102 (100%)
127 (67%) 62 (33%) 189 (100%)
18 (64%) 4 (14%) 4 (14%) 28 (100%)
19 (79%) 6 (25%) 2 (8%) 24 (100%)
58 (71%) 23 (31%) 8 (11%) 75 (100%)
95 (75%) 33 (26%) 14 (11%) 127 (100%)
*
Total excludes missing or invalid responses. Total excludes respondents who were skipped because of branching logic.
†
may hesitate to admit a near miss or have different definitions of types of errors or complications to report.10 For example, problems that did not reach the patient may not be considered error averted or inefficiency and therefore go unreported. Perceptions varied across disciplines, indicating different points of view. Most of the respondents replied that the checklist had a positive impact on efficiency, including preventing delays and improving flow in the operating room. These results contrast with anecdotal reports that use of a checklist adds time to each case and negatively impacts efficiency. They also provide evidence for addressing skeptics. Efficiencies associated with checklist use may stem from better case preparation before and during the procedure that facilitates smooth operations. Despite initial concern among some professionals that staff introductions were unnecessary or a waste of time, the findings suggest that most supported the introductions, agreeing that these improved familiarity, helped establish a comfortable environment, and set the tone for improved communication and teamwork throughout the case. The literature also supports the use of team introductions. Studies have found that failures in team communication, failure to feel empowered to speak up, and failure to ask questions have all led to sentinel events.11 The results indicated that the checklist length was satisfactory for most cases. Some respondents felt that the checklist was too long, leading to checklist overload or fatigue, and noted that some content was not relevant for every procedure, particularly “short” procedures. Standardized checklists may not be appropriate for the wide variety of surgical services and diversity of procedures performed on a daily basis. Without modifying the checklist for greater relevance, long-term success and compliance may be difficult to attain. This suggests that the more value staff members attribute to checklist content, the more satisfied they may be with its length and the more likely that they may be to comply with using the checklist. Finally, the results indicate that a majority of staff members would want the checklist used with their own child for any case or for certain cases. The responses received indicate that the staff believes that patients are safer with the current checklist than without it but that there may be room for improving the checklist, thereby adding value to current checklist content. For those who responded negatively to this question, their resistance may stem from negative or indifferent feelings toward the implementation process or a valid concern regarding the checklist. Responses to the survey varied by professional discipline. The nurses cited a higher rate of site marking or consent-related
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problems, whereas the surgeons cited a higher rate of antibiotic and equipment-related problems. The nurse respondents were nearly twice as likely as the physicians (attending anesthesiologists or attending surgeons) to report observing a prevented error or complication. In a teaching hospital, the operating room nurse is often the only team member who remains with the patient throughout the entire operative procedure, whereas both the attending surgeon and the attending anesthesiologist may not be continuously present. The nurses therefore may observe problems that the attendings do not witness. In addition, it is the nurse's responsibility to review the written consent, procedure, and site marking with the patient and family before surgery. Surgical residents or fellows may resolve errors or discrepancies identified in these activities before an attending physician observes them. On the other hand, the surgeons reported antibiotic-related errors more frequently than did other disciplines. This may reflect surgeons’ concern with compliance with Surgical Care Improvement Project measures and thus greater sensitivity to reporting delays in administering antibiotics prevented by the checklist. Such differences between disciplines make the implementation of an improvement intervention such as a safe surgery checklist a complex endeavor requiring strong leadership and a tailored approach to communicating the importance of checklist use. Communicating the problems averted by the checklist to clinicians could raise awareness and promote sustained compliance. Efficiency was also viewed differently among disciplines. The nurses more often than the physicians observed efficiency improvements due to the checklist. They also more often viewed the checklist as a vehicle to improve communication. Efficiency may be less visible to the surgeon and the anesthesiologist, who may be focused on specific procedural needs. Sharing the nurses' perspective on benefits of the checklist could be helpful in convincing surgeons and anesthesiologists that the checklist can improve efficiency. However, it may be important to find a way to visibly demonstrate these improved efficiencies to sustain checklist use. With the results of the survey, it is important to identify and comprehend why some clinicians feel that the checklist does not add value to their current practice. These concerns might present opportunity for further modification to improve the checklist or its implementation. This is a question for further research and for one-on-one discussions with individual clinicians. When an institution is committed to using a checklist, its leaders must identify and address legitimate concerns before enforcing its use. Differences in opinion regarding the types of errors averted suggest that © 2014 Wolters Kluwer Health, Inc. All rights reserved.
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J Patient Saf • Volume 12, Number 1, March 2016
Pediatric Surgical Safety Checklist
TABLE 5. Survey Response by Professional Discipline—Opinions About the Hospital's Surgical Safety Checklist
Opinions Team introductions have affected the conduct of the operation (Check all that apply) Improved familiarity Helped set tone Open environment No difference Negative impact Unsure Total Current number of items on the checklist Just right Too many Not enough Total* Would you want the checklist used on your own child undergoing surgical procedure? Any case Certain cases Not any case Unsure Total*
Surgeon n = 49
Anesthesiologist/CRNA n = 40
RN/SST n = 107
Combined N = 196
34 (71%) 30 (63%) 23 (48%) 6 (13%) 2 (4%) 2 (4%) 49 (100%)
26 (65%) 26 (65%) 15 (38%) 8 (20%) 0 (0%) 2 (5%) 40 (100%)
35 (52%) 48 (46%) 45 (43%) 11 (10%) 2 (2%) 7 (7%) 107 (100%)
115 (60%) 104 (54%) 83 (43%) 25 (13%) 4 (2%) 11 (6%) 196 (100%)
31 (66%) 16 (34%) 0 (0%) 47 (100%)
26 (67%) 12 (31%) 1 (3%) 39 (100%)
67 (66%) 32 (32%) 2 (2%) 101 (100%)
124 (66%) 60 (32%) 3 (2%) 187 (100%)
33 (73%) 5 (11%) 3 (7%) 4 (9%) 45 (100%)
30 (77%) 3 (8%) 2 (5%) 4 (10%) 39 (100%)
86 (85%) 9 (9%) 0 (0%) 6 (6%) 101 (100%)
149 (81%) 17 (9%) 5 (3%) 14 (8%) 185 (100%)
*
Total excludes missing or invalid responses.
individuals with different backgrounds and responsibilities are sensitive to different issues and bring unique perspectives to the operating room environment. These differences have the potential to threaten patient safety because surgery increasingly requires groups of individuals to work together as multidisciplinary teams rather than in separate “silos.” Effective use of the safety checklist requires entire teams to change behavior.
options, which included more positive than negative choices, may have biased the respondents toward more positive responses. The limited use of open-ended questions did not permit those with concerns to voice them fully. However, our results could be instructive as a measure of attitudes of personnel in health care facilities where the checklist was not implemented as part of an organized study. Despite these limitations, this study confirmed the belief that the staff has largely accepted the use of the checklist at this pediatric academic teaching hospital.
Limitations Our study should be viewed in the context of its limitations. One limitation of this study is the exclusion of surgical and anesthesia residents, fellows, and traveling nurses. At the time of the study, this group had limited or no exposure to the checklist in our setting, which reduced the value of their feedback. However, future research should include this perspective. Another limitation was a response rate of 49%, which presents the possibility of selection bias. The respondents to the survey were experienced with long tenure at this hospital. Their exposure to prior safety efforts suggests that they may be more accepting of the checklist than less experienced personnel. Most of the respondents had been exposed to a series of patient safety efforts since 2004. The study team believes that a highly satisfied and experienced staff with patient safety experience may be relatively more inclined to accept the implementation of a new surgical safety checklist than the general population. Further, there were no comparative prechecklist data to estimate the effect of checklist implementation before and after. Response rates were not consistent across all disciplines, leaving open the possibility that differences among disciplines were a function of different response rates rather than different attitudes. The survey was not developed with an expectation that results could be generalized or applied to a larger population. Response © 2014 Wolters Kluwer Health, Inc. All rights reserved.
CONCLUSIONS The Pediatric Surgical Safety Checklist is generally supported and thought to improve patient safety to some degree by most of the surgical staff members at the hospital in which it was implemented. Overall, the survey affirmed that the surgical staff viewed the checklist as potentially beneficial to operative patient safety by improving teamwork and communication, reducing errors, and improving efficiency to some degree. Teams that use checklists in health care do so to minimize complications or errors in treatment. Although some of the survey findings could be interpreted as negative, the study team was struck by the predominantly positive nature of the comments. Very few individuals claimed that they would not want the checklist used with their child, responded negatively, or indicated that the checklist was overbearing at times. Enthusiasm for checklist use could be enhanced in several ways. First, raising awareness about situations in which the checklist averted a potential critical event could promote overall support of the checklist. Presenting concrete data on improved efficiency directly related to the checklist is another means to gain further support from those who want more evidence on the effectiveness of the checklist. Results from in-house surveys of staff perceptions provide data on colleagues’ perceptions, which may www.journalpatientsafety.com
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also be persuasive when shared. Collecting and providing all these types of information may help maintain and sustain checklist compliance. Checklist implementation requires a culture of safety, multifaceted intervention, and education. As the checklist becomes more widely accepted and the content is revised for more relevance to specific procedures, those remaining reluctant clinicians may increasingly support and sustain its use. However, mandates or other disciplinary action may ultimately be required to engage those who resist using it. Further work is needed to refine checklist content and to determine effective strategies for implementing checklists and sustaining their effect.
7. World Health Organization. Patient safety: Surgical Safety Web Map. 2012. Available at: http://maps.cga.harvard.edu:8080/Hospital/. Accessed May 31, 2013.
REFERENCES
8. Norton EK, Rangel SJ. Implementing a pediatric surgical safety checklist in the OR and beyond. AORN J. 2010;92:61–71.
1. Institute of Medicine (U.S.). Committee on Quality of Health Care in America. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: National Academy Press; 2001.
9. Sexton JB, Helmreich RL, Neilands TB, et al. The Safety Attitudes Questionnaire: psychometric properties, benchmarking data, and emerging research. BMC Health Serv Res. 2006;6:44.
4. Neily J, Mills PD, Young-Xu Y, et al. Association between implementation of a medical team training program and surgical mortality. JAMA. 2010; 304:1693–1700. 5. Mainthia R, Lockney T, Zotov A, et al. Novel use of electronic whiteboard in the operating room increases surgical team compliance with pre-incision safety practices. Surgery. 2012;151:660–666. 6. Conley DM, Singer SJ, Edmondson L, et al. Effective surgical safety checklist implementation. J Am Coll Surg. 2011;212:873–879.
2. de Vries EN, Prins HA, Crolla RM, et al. Effect of a comprehensive surgical safety system on patient outcomes. N Engl J Med. 2010;363: 1928–1937.
10. Jeffs LP, Lingard L, Berta W, et al. Catching and correcting near misses: the collective vigilance and individual accountability trade-off. J Interprof Care. 2012;26:121–126.
3. Haynes AB, Weiser TG, Berry WR, et al. A surgical safety checklist to reduce morbidity and mortality in a global population. N Engl J Med. 2009; 360:491–499.
11. Lingard L, Espin S, Whyte S, et al. Communication failures in the operating room: an observational classification of recurrent types and effects. Qual Saf Health Care. 2004;13:330–334.
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