Safety Checklist Briefings: A Systematic Review of the Literature DIANA SOULE McDOWELL, MSN, RN, CNOR, CPHQ; SARA A. McCOMB, PhD, PE

ABSTRACT Nearly half of all surgical complications are considered preventable. Early research regarding preprocedural surgical safety checklist briefings revealed that this process led to improved surgical complication rates. We conducted a literature search to gather evidence regarding compliance in conducting briefings, outcomes of briefings, and surgical team members’ perceptions toward the use and efficacy of checklist briefings. We found 23 studies conducted in 17 countries, the majority published since 2011, addressing these elements. The studies used a variety of methodologies and outcome measures. Common themes in the studies included enhanced patient safety, improved compliance over time, and increased communication among team members when checklists were used. As research continues on surgical safety checklists and briefings, a great opportunity exists for perioperative nurses to make contributions to the evidence. AORN J 99 (January 2014) 125-137. Ó AORN, Inc, 2014. http://dx.doi.org/10.1016/j.aorn.2013.11.015 Key words: surgical safety, checklists, literature review.

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urgical patients make up a significant portion of health care recipients worldwide. The estimated minimum volume of major surgical procedures globally for 2004 was 234 million.1 To put this in perspective, these results translate into about one surgery for every 25 people on earth in 2004.1 Complication rates for surgical patients in industrialized countries have been estimated to range from 3% to 16%, and mortality rates range from 0.4% to 0.8%.1-3 Mortality rates associated with major surgeries in developing countries have been estimated at 5% to10%.4 The National Center for Health Statistics reported that death rates in the United States from complications of medical and surgical care among

adults 45 years and older dramatically decreased from 1999 to 20095: n

in adults 85 years and older, deaths declined 39% to 71.3 in 100,000, n in adults 75 to 84 years, deaths declined 37% to 51.4 in 100,000, n in adults 65 to 74 years, deaths decreased 38% to 27.9 in 100,000, and n in adults 45 to 64 years, deaths decreased 28% to 8.9 in 100,000. Van Den Bos et al6 identified approximately 564,000 inpatient and 1.8 million outpatient injuries from medical claims data from January 2000 to September 2008. They noted that among

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the most frequent medical errors related to surgical procedures were postoperative infections, hemorrhage, accidental puncture or laceration, mechanical complication of noncardiac devices, and hematoma. 6 Many data sources and studies have focused on adverse events and complications resulting from surgical procedures. In 2009, the National Patient Safety Agency reported that the number of incidents related to surgical procedures for 2007 in England and Wales was 129,419.7 In the United States, Classen et al8 reported that 109 of 393 (28%) adverse events measured by three different methods were procedure related in three hospitals. In researching medical insurance claims in Colorado from 2002 to 2008, Stahel et al9 determined that wrong-site procedure errors were far more common in surgical patients than nonsurgical patients, with 97% of those errors causing varying degrees of harm or impairment. Surgical complications have been associated with increased lengths of stay, ranging from nine days for minor complications to 14 days for major complications.10 The same analysis found that an increase in hospital costs for one visit (adjusted for complexity, patient characteristics, and comorbidities) could exceed $54,000.10 More recent research conducted by Eappen et al11 reviewed surgical complications and their effects on hospital finances. They reviewed surgical complication data from 2010 from a 12-hospital system and found that of 35,394 surgical inpatients, a total of 1,820 procedures had at least one complication, resulting in a median length of stay of 14.0 days, as opposed to a length of stay of 3.0 days for those patients without complications. They also found that the occurrence of one or more complications translated to a higher per-patient variable cost ($22,398) and a higher per-patient total cost ($37,917).11 CAUSES OF COMPLICATIONS Surgical complications are varied and often result in error or omissions in practice. The most notable errors are wrong procedure, wrong patient, wrong 126 j AORN Journal

McDOWELLdMcCOMB site surgeries and retained surgical items. Complications also can be the result of a lack of preparation. Preventative measures, including proper identification of surgical specimens and of patients who are at risk for high blood loss, anesthesia or airway issues, adverse medication reactions, and surgical site infection, have been identified as essential practices for optimal surgical safety.4 Researchers have suggested that nearly half of all surgical complications are preventable.2,3,12 The surgical team is important in the prevention of surgical errors. Research in surgical safety has identified that breakdowns in communication and teamwork resulted in approximately 43% of surgical incidents.13 Communication failures have been observed involving all team members, regardless of authority or experience levels, often resulting in team members being silent or retreating from communication during a surgery to varying degrees.8,9,13-15 Cognitive failings, such as reliance on memory, and variances of task standardization also have been found to be contributing factors to error.11,12,16-18 CHECKLIST BRIEFINGS Safety checklist briefings serve as standardized frameworks for every procedure and have been credited for improving error and complication rates.16 One of the first widely implemented and studied examples of a surgical safety checklist is the World Health Organization (WHO) Surgical Safety Checklist.12,19 Another safety checklist, the SURgical PAtient Safety System (SURPASS) checklist, was developed in the Netherlands to address perioperative safety measures like the WHO checklist but also includes a significant postoperative component.20 Checklist briefings may promote behavioral changes in surgical team members, specifically in communication, which is considered to be at the heart of patient safety performance.13,16 Some team members find the communication changes that checklist briefings create, particularly the selfintroductions at the beginning of the procedures,

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difficult to implement because of ingrained behavior checklist briefings were observed to be inconsis15 patterns. The Committee on Quality of Health Care tent.18 Some participants felt that the checklist in America determined that “People make fewer briefings were inconvenient, depending on when 16(p173) mistakes when they work in a team.” they occurred in the preoperative preparation They workflow.18 In another study, 13% of respondents also noted that when team processes are planned and standardized, each member of the team knows the polled noted that the absence of consequences for not other team members’ functions, and errors may be completing the checklist briefing reduced integranoticed before they cause an incident.16 Stahel et al9 tion of the checklist into the hospital procedures.20 determined that performing safety checklist briefRegardless of the inconsistent compliance in the ings contributed to better patient outcomes and that implementation of checklists as a whole, providers 72% of the wrong site procedures resulted because of agree that checklists are important.23 For example, the lack of performing a time out. participants in the WHO checklist project were The initial study that examined the effectiveness surveyed three months after the initiation of the of the WHO checklist briefing revealed that this safety checklist briefing. Most had been skeptical process could be effective in the prevention of about implementation of the checklist initially, but surgical complicaafter implementation, 12 tions. The posttest 80% responded that study determined the process was easy Regardless of the inconsistent compliance in the implementation of checklists as a whole, a baseline surgical to use, quick to comproviders agree that checklists are important. complication rate of plete, and improved 11% and surgical patient safety. The mortality rate of 1.5%. remaining 20% did After researchers educated surgical team members not answer in the affirmative, but 93% of the on the checklist briefing process, checklist briefings respondents indicated that if they were to have were initiated in the ORs and complication rates an operation, they would want the checklist fell to 7.0% and surgical mortality rates fell to used.23,24 0.8%.12 In a subsequent study, many of the same Recently, Borchard et al25 published a systemresearch team members determined that the use atic review and meta-analysis of literature from of the checklist would save more than $100,000 1995 to April 2011 regarding safety checklists; annually for a hospital that performed 4,000 nontheir effectiveness; and compliance in usage, critcardiac surgeries per year, a savings of $25.96 per ical factors, and team attitudes toward them. This 21 case. team of public health professionals concluded that More than 300 health care associations, professurgical mortality and morbidity were decreased sional societies, individual hospitals, health care with the use of checklists and that team members systems, and governmental agencies throughout were, overall, compliant. They also noted that the world have endorsed the WHO Safe Surgery further research was needed, particularly regarding Initiative and the development of the WHO Surchecklist implementation. 22 gical Safety Checklist. As of 2012, the WHO Around the same time that Borchard et al25 were reported that 1,790 facilities worldwide were acpreparing their review, Gawande’s book, The 22 tively using the checklist. Checklist Manifesto,23 was increasing the visibility Initially, not all components were used by those of surgical safety checklists. This increasing awarewho adopted the checklist, and their use was not ness has led to a dramatic increase in the number of consistent within the same institutions. In a 2005 studies being published. Our review identified 14 Canadian pilot study, the timing and location of the studies that had not yet been published by April AORN Journal j 127

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Ambulatory Takeaways Resources for Checklists in Ambulatory Surgery Centers The Centers for Medicare & Medicaid Services (CMS) finalized a quality reporting program for ambulatory surgery centers (ASCs), including endoscopy centers, in 2012.1 One of its structural measures was use of a safe surgery checklist. Personnel at ASCs and office-based ORs can contribute to the body of evidence through the CMS quality measures. Much can be learned from Quality Assurance & Performance Improvement (QAPI) projects. Many resources are available for ASCs that provide educational opportunities and assistance with data collection, analysis, and distribution for benchmarking and best practices. An ASC may use any safe surgical checklist as long as it addresses effective communication and safe surgery practices in each of three perioperative periods: before administering anesthesia, before incision, and before the patient leaves the OR. Some examples of checklists developed by professional organizations include the following, which are customized but adhere to the same perioperative timeframes as the World Health Organization Surgical Safety Checklist2: n

Correct Site Surgery Tool Kit. AORN, Inc. http://www.aorn.org/Clinical_Practice/ToolKits/Correct_Site_Surgery_Tool_Kit/Correct_Site_ Surgery_Tool_Kit.aspx. n Ophthalmology Safe Surgery Checklist. American Society of Ophthalmic Registered Nurses. http://www.asorn.org/resources/safe_surgical_checklist. n Gastroenterology Safe Surgery Checklist for Ambulatory Surgical Centers. The American Society for Gastrointestinal Endoscopy. http://www.asge.org/assets/0/71550/71552/0a052c8d-43ae-489e-80ed-7c7a822cbe4f.pdf. n Safety Checklist for Office-Based Surgery. Institute for Safety in Office-Based Surgery. http://isobsurgery.org/wp-content/uploads/2012/03/safety-checklist.jpg. The implementation of a surgical safety checklist is also an element in a national patient safety improvement collaborative funded by the Agency for Healthcare Research and Quality.3 This program meets the CMS requirements of coverage for QAPI projects and provides educational opportunities and assistance with data collection, analysis, and distribution for benchmarking and best practices. Many survey agencies have recognized the importance of offering support to ASCs and supporting CMS conditions of coverage and quality reporting and all endorse a safe surgical checklist. Consistent and standardized measures will allow ASCs to benchmark and learn from those facilities demonstrating best practices. Terri Link, MPH, RN, CNOR, CIC, is an ambulatory education specialist at AORN. Ms Link has no declared affiliation that could be perceived as posing a potential conflict of interest in the publication of this article. 1. 2. 3.

ASC quality reporting. Centers for Medicare & Medicaid Services. http://www.cms.gov/Medicare/Quality-Initiatives-Patient -Assessment-Instruments/ASC-Quality-Reporting/. Updated August 16, 2012. Accessed October 14, 2013. WHO surgical safety checklist and implementation manual. World Health Organization. http://www.who.int/patientsafety/safesurgery/ ss_checklist/en/. Published 2008. Accessed October 14, 2013. AHRQ’s safety program for ambulatory surgery. Agency for Healthcare Research and Quality. http://www.ascsafetyprogram.org/. Accessed October 14, 2013.

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SAFETY CHECKLIST BRIEFINGS 2011, when Borchard et al25 completed their review. Therefore, our review of the literature captures this rapidly growing phenomenon in surgical suites worldwide. Additionally, we expand the perspective from which these studies are assessed by incorporating a perioperative nursing lens to our analysis of surgical safety checklist briefings, which, to our knowledge, has not been done in previous reviews. PURPOSE OF THE LITERATURE REVIEW AND OBJECTIVES The purpose of this systematic review was twofold. First, we evaluated the evidence regarding three dimensions of preprocedural surgical safety checklist briefings: compliance in conducting briefings, outcomes of briefings, and surgical team members’ perceptions of the process. Second, we identified how the results may affect perioperative nurses and how perioperative nurses can contribute to the evidence base. REVIEW METHODS We conducted a systematic literature search within the PubMedÒ database of the National Library of Medicine to obtain all possible research articles published through mid-October 2012 related to the use of preprocedural checklist briefings (eg, sign in, time out). Selected studies included the intervention of preprocedural briefings structured by surgical safety checklists. Search filters included articles written in English with abstracts; the criteria further excluded editorials, news items, and position statements. The list of Medical Subject Headings included in the search strategy is noted in Figure 1. Using the aforementioned strategy, we initially retrieved 125 articles, which we reviewed and selected for inclusion. Sixty-nine articles discussed clinical areas other than surgical or perioperative service lines (eg, reproductive health, dentistry, radiology, global health), making them irrelevant to our review. In addition, we eliminated 18 articles (including opinion pieces, book reviews, and announcements) that addressed surgical safety

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checklist briefings but were not studies, eight studies that focused on surgical safety but did not include the use of a checklist, and seven studies that centered on interventions involving checklist briefings but measured outcomes from initiatives surrounding those implementations (eg, characteristics of effective leadership during implementation, team training, attitude differences across team member categories). We retained the remaining 23 studies for inclusion in this study. Supplementary Table 1 contains the studies that measured compliance with checklist briefings, Supplementary Table 2 contains the studies that measured clinical and logistical outcomes, and Supplementary Table 3 contains the studies that measured surgical team members’ perceptions or attitudes regarding the checklist briefing process (view Supplementary Tables 1-3 at http://www.aornjournal.org). Studies that measured more than one type of result (eg, compliance and outcomes, perceptions and compliance) appear in multiple tables. FINDINGS All of the articles were published between 2006 and 2012, with 16 published between 2011 and mid2012. Four studies were conducted in the United Kingdom; three in the United States; three in the Netherlands; two in Canada; two in Finland; and one each in Germany, Iran, Israel, Liberia, New Zealand, Norway, Sweden, and Thailand. A multinational study conducted by the WHO Safe Surgery Saves Lives Campaign included sites in Canada, India, Jordan, New Zealand, Philippines, Tanzania, the United Kingdom, and the United States. Studies included in this review were quasiexperimental. All studies were quantitative with the exception of two team perception studies. We ascertained the level of evidence using the “Rating System for the Hierarchy of Evidence” adapted by Fineout-Overholt et al.26 The studies used many different methodologies, even within major study categories, resulting in silos of conclusions. Only one of the 23 studies reviewed was classified as a randomized controlled AORN Journal j 129

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Figure 1. Search terms and the flow diagram for decisions regarding acceptance or elimination from the review. PubMed is a registered trademark of the US National Library of Medicine, Bethesda, MD.

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SAFETY CHECKLIST BRIEFINGS trial (ie, classified as Level II using the FineoutOverholt et al26 rating system). The other studies were either case-control or cohort studies (ie, Level IV) or qualitative or descriptive studies (ie, Level VI). Therefore, drawing any generalized conclusions about the compliance, outcomes, or staff perceptions of checklist briefings and their efficacies is challenging. We were, however, able to draw common themes across categories, identify implications for perioperative nurses based on these themes, and provide recommendations for practice and future research. Compliance Studies Among the 12 studies that measured compliance in performing briefings and completing checklists, researchers used three basic methods: observation, self-report, and audit. Eight studies used direct observation in evaluating surgical team members’ completion of the checklist briefing processes.20,27-33 Three studies used auditing of surgical records to determine measurement of compliance.34-36 In a study by Kasatpibal et al,37 RN circulators in the OR contributed by self-reporting compliance and variation data regarding the checklist briefing completions. For the purposes of this review, we chose five categories of compliance, or improvement in compliance, to provide an illustration of the significant findings of those studies: n n n n n

overall compliance, verification of patient identity, verification of procedure, verification of operative site, and notation of pertinent patient history (eg, allergies, risks).

The results of six studies indicate significant rates of compliance ( 95% or P < .001); five measured increased compliance,29-31,35,36 and one measured the decrease in observed communication failures.32 We found verification or discussion of the surgical procedure to be significantly compliant in five studies.27-30,37 Patient identity verification was significantly compliant in four studies,27,29,30,37

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and the identification of the surgical site was significantly compliant in three studies.29,30,37 We found that recognition of pertinent patient history, including allergies and risks, was significantly improved by the use of checklist briefings in two studies.28,30 Although improvement in overall compliance in the completion of structured (ie, checklist) briefings was described, researchers did not report 100% compliance in any studies.20,27-37 Seven of the 12 studies measured compliance with individual checklist items.27-31,36,37 The elements that these studies addressed with the highest frequencies were verifications of the patient’s identity and surgical site and the procedure to be performed.29,30,37 In repeated postintervention studies, researchers validated improvement in compliance; two studies demonstrated overall improvement in compliance over time, and a third addressed improvement in the specific measure of venous thromboembolism prophylaxis.29,33,35 Outcome Studies We found six studies on outcomes associated with checklist briefings. Askarian et al36 reported a statistically significant decrease (P ¼ .03) in any complications. de Vries et al38 measured closed claims against corresponding items on the SURPASS checklist; the most notable statistic was a 69% overall correlation between safety breeches contained in the closed claims and checklist items, such as wrong patient, procedure, side, and site. In 2012, de Vries et al34 collected 6,313 checklists from six individual hospitals, including self-reports of “intercepted incidents” by checklist users; they discovered a total of 6,312 incidents by use of the SURPASS checklist, including 3,458 (54.8%) preoperative incidents and 897 (14.2%) perioperative incidents. A study conducted in Liberia measured overall complications and surgical site infections in two different hospitals and pooled scores; this study showed significantly improved outcomes (P < .0001 for any complication; P < .005 for surgical AORN Journal j 131

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site infections).31 Einav et al39 measured “nonrouwhich often has been one rationale for not institine” events (ie, near misses, events that could have tuting preprocedural briefings.40 caused patient harm) as the basis for their study Perception Studies of checklist briefing outcomes. Nonroutine events Several different methods were used by investiincluded a number of activities, such as missing gators looking at team member perceptions or laboratory values, unprepared equipment, and attitudes regarding the closing the wound use of checklist briefing before the surgical count. The mean of In several studies, establishing team members’ interventions, including both quantitative and nonroutine events per identities and roles during safety checklist qualitative methods. procedure with briefbriefings was felt to enhance awareness of ings was found to be each member’s identify and function, including For the purposes of 1.6, compared with perceptions of being valued as a team member. this review, we used the five most common 2.1 for those prosurvey questions or cedures without briefcategories to discuss the results. We considered ings (P < .004) if at least 25% of the checklist the results in this review significant if responses items were completed; the mean was further rewere 80% or greater, significant as related to the duced to 1.45 if briefings included at least 40% 39 investigators’ statistical methods (ie, as desigof checklist items. A study on the influence nated in their studies), or, in the case of the of checklist briefings on surgery start times con40 qualitative studies, significant if there were ducted by Ali et al in two teaching hospitals commonly repeated words or phrases in subshowed no statistical difference in surgery start jects’ responses. times when briefings were added to the surgical One category of perception questions focused care routine. on team member introductions, their roles and reIn summary, data demonstrated that checklistsponsibilities during the procedure, and the positive guided briefings contributed to the prevention of perception of respondents in feeling like part of untoward events during procedures and reduced the team. Five of seven studies asking about postoperative complications. The occurrence of team introductions had significantly positive repotential intraoperative incidents (ie, clinical errors, sponses.27,39,41-43 Seven of the eight studies that nonroutine events) were shown to be improved by the use of the checklist briefings in two studies.34,39 asked about improvements in team communications or discussions demonstrated overall positive One study also stratified the results by measuring responses.24,32,33,40,41,44,45 In five studies,33,41-43,46 the number of nonroutine events by the percent of a cross-sectional method was used, and the sigchecklist items that were completed, demonstrating nificant results were those of nurses and “nonthat an increase in the number of items completed medical” (ie, ancillary) members of the teams. resulted in a related decrease in the number of 39 Responses indicating team perceptions that checkoccurrences. Postoperative complication mealist briefings contributed to better awareness of surements included the occurrence of any complipatient-centered information (eg, identification, cation or surgical site infection, and, in one case,38 risks, specific issues) were included in the surveys researchers compared contributing factors of closed of seven studies,24,32,40-44 five of which had signifclaims as they related to the individual elements 31,36 icant results that were positive.40-43,44 of the checklist briefing. Another study demAnother category, improvement in team awareonstrated that briefings did not significantly conness of the procedure, or situational awareness, tribute to delays in starting surgical procedures, 132 j AORN Journal

SAFETY CHECKLIST BRIEFINGS appeared in five studies; four of these reported significantly positive responses.39-42 Five of the studies examined the overall contribution of surgical safety checklist briefings to patient safety or error prevention.24,32,39,44,47 All five studies had significantly positive responses from the participants. Team members who were surveyed on the effectiveness of safety checklist briefings had positive responses for the briefings being important to overall patient safety.24,32,39,44,47 Specific responses also included positive reactions to improvements in the identification of potential equipment problems and clinical issues.46,47 Team members revealed that they were provided with more pertinent information regarding the patient, procedure plan, and potential risks of the procedure, thereby demonstrating an overall increase in situational awareness.27,39-42 Establishing team members’ identities and roles during the briefings was felt to enhance awareness of each member’s identify and function, including perceptions of being valued as a team member.33,39,41-43,45 Lastly, survey responses were positive regarding improvements made in team discussions (case specifics) and overall communication.24,32,33,40-42,45 Respondents also reported that strengthened teamwork and efficiency were positive aspects of safety briefings.39,42,43 DISCUSSION The growing body of evidence supporting the use of surgical safety checklist briefings provides strong support for their continued use. At the same time, however, the quality and consistency of evidence points to the possibility of bias in any assessment of results and several opportunities for improving research in the future. First, only one identified study was a randomized controlled trial. The other studies were predominately pre-post examinations (ie, measurements taken before and after the implementation of the checklist) or single, typically postdescriptive studies, and two were

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qualitative studies. Although all types of research provide useful information as a field is developing, the consistently positive results suggest that more randomized controlled trials are warranted to bolster the confidence in the utility of surgical safety checklist briefings and continue the trend toward more thorough application of these briefings in practice. Second, the studies we reviewed focused on a variety of measures relating to surgical safety checklist briefings, ranging from generalized compliance with the process to compliance with specific elements and from comparisons of start times to measurement of team comfort levels with the process. Although these measures provide useful information about checklist briefings, the inconsistency limits our ability to draw generalized conclusions and/or conduct meta-analyses to identify systematic patterns across results. Although we took care in identifying themes across the studies we reviewed, the aforementioned opportunities for future research also suggest a potential for bias in our conclusions. For example, bias in the form of a limited sample size may be considered in two of the perception studies.45,46 Measurement bias also may have influenced our conclusions. For instance, in one study, the survey results were recorded as common descriptions rather than responses with given numeric weight that could be statistically analyzed.48 Limitations of Review We only used the PubMed database to search for studies. We focused our selection only on preoperative and intraoperative aspects of safety checklist briefings. Many checklists also include a sign-out portion for which the team n

reviews the completed procedure, comparing it with the procedure consent; n verifies that sponge, sharp, and instrument counts have been completed; n verifies that specimens have been identified and labeled;

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identifies any equipment problems to be addressed; and n discusses any key concerns for the recovery and management of the patient. Although we fully acknowledge that the sign-out portion of this safety process is an important element, it did not fit within the scope of our review. We also did not capture another safety process, The Joint Commission’s Universal Protocol for Preventing Wrong Site, Wrong Procedure, and Wrong Person SurgeryTM, in the results of this search, although we certainly acknowledge the contributions that it has made to surgical patient safety.

McDOWELLdMcCOMB in the surgical suite. In practice, perioperative nurses are in the best position to make the appropriate introductions and provide guidance for positive interactions and learning experiences. In summary, when perioperative nurses facilitate the surgical safety checklist briefing, they are advocating not only for the patient but for their fellow team members.

Recommendations The purpose of this systematic review was to evaluate the current evidence and to inform perioperative nurses regarding the current evidence addressing surgical safety briefings guided by checklists. The three categories of interest were compliance in the completion of briefings, outImplications for Perioperative Nursing comes when briefings have been performed, and Perioperative nurses play a pivotal role in the team perceptions regarding the performance of effectiveness of safety checklist briefings. They briefings. The use of surgical safety checklist have a direct effect on compliance with safety briefings has continued to grow, as demonstrated checklist briefings because they are most often by the increase in responsible for the published research; initiation, leadership, in this review alone, and documentation of The use of surgical safety checklist briefings has continued to grow, as demonstrated by the 16 of 23 studies were this safety measure. increase in published research; in this review published in 2011 and They have great opalone, 16 of 23 studies were published in 2012. Although comportunities to gain mon themes have been increased understand- 2011 and 2012. identified across these ing of the relevance studies, a direct comof performing checkparison of results was not possible because of the list briefings by reviewing the ever-growing body variety of methods and measurements (ie, perof evidence that supports the advantages of checkcentages, means, verbal descriptions), making it list briefings. a challenge to draw any generalized conclusions. It The studies we reviewed offer evidence that is therefore recommended that additional studies be these safety processes are effective methods for conducted using standardized methodologies and preventing errors and injuries to patients and accommon outcomes to facilitate more comprehencomplishing safety in a timely fashion. The results sive comparisons. of the team perception studies suggest that surgical team members understand the relevance of using CONCLUSION the checklist briefings. In particular, this seems Perioperative nurses are not only integral members to be true for improved situational awareness reof the surgical team, but in many cases they are garding patients and procedures and recognizing responsible for initiating a briefing and documenting other team members and their roles. The studies directly on a checklist or attesting that a checklist demonstrated the value of introductions, including has been completed. The overwhelming majority of new team members, students, and other observers 134 j AORN Journal

SAFETY CHECKLIST BRIEFINGS research on these topics is found either in the medical or general health care safety literature, opening an opportunity for perioperative nurses, educators, and researchers to further enhance this body of evidence through nursing research. Perioperative educators, both in formal and informal settings, have great opportunities to use study results such as those discussed in this review to teach and support the performance of safety checklist briefings. Safety is crucial in all aspects of perioperative education, including academic education, staff orientation, and continuing education. As the compliance studies noted, often there is not a 100% completion of the checklist briefing, an outcome that can certainly be influenced by education. Perioperative nurses should be encouraged to look for opportunities to conduct their own research. For example, the use of proven, standardized survey tools has the potential to contribute common data to the existing evidence. Replication of existing studies and case studies demonstrating best practices and outcomes are other methods that perioperative clinicians and researchers can contribute to the body of evidence. Perioperative nurses possess a wealth of information and experience regarding safety practices that provide them with a great potential to contribute to the evidence and enhance surgical safety. SUPPLEMENTARY DATA Supplementary tables associated with this article can be found in the online version at http://dx.doi .org/10.1016/j.aorn.2013.11.015. Acknowledgment: The authors thank Maribeth Slebodnik, RN, MLS, associate professor of library science, Purdue University, West Lafayette, IN, for her assistance and guidance during this project. Editor’s notes: PubMed is a registered trademark of the US National Library of Medicine, Bethesda, MD. The Universal Protocol for Preventing Wrong Site, Wrong Procedure, and Wrong Person Surgery

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is a trademark of the Joint Commission, Oakbrook Terrace, IL. References 1. Weiser TG, Regenbogen SE, Thompson KD, et al. An estimation of the global volume of surgery: a modeling strategy based on available data. Lancet. 2008;372(9633): 139-144. 2. Gawande AA, Thomas EJ, Zinner MJ, Brennan TA. The incidence and nature of surgical adverse events in Colorado and Utah in 1992. Surgery. 1999;126(1): 66-75. 3. Kable AK, Gibberd RW, Spigelman AD. Adverse events in surgical patients in Australia. Int J Qual Health Care. 2002;14(4):269-276. 4. Gawande AA, Weiser TG, eds. WHO Guidelines for Safe Surgery. Geneva, Switzerland: World Health Organization; 2008. 5. Centers for Disease Control and Prevention. QuickStats: death rate* from complications of medical and surgical care among adults aged  45 years, by age groupd United States, 1999d2009. Morbidity and Mortality Weekly Report. September 21, 2012. http://www.cdc.gov/ mmwr/preview/mmwrhtml/mm6137a6.htm?s_cid¼mm6 137a6_w. Accessed September 12, 2013. 6. Van Den Bos J, Rustagi K, Gray T, Halford M, Ziemkiewicz E, Shreve J. The $17.1 billion problem: the annual cost of measurable medical errors. Health Aff (Millwood). 2011;30(4):596-603. 7. Reid J, Clark J. Progressing safer surgery. J Perioper Pract. 2009;19(10):336-341. 8. Classen DC, Resar R, Griffin F, et al. “Global trigger tool” shows that adverse events in hospitals may be ten times greater than previously measured. Health Aff (Millwood). 2011;30(4):581-589. 9. Stahel PF, Sabel AL, Victoroff MS, et al. Wrong-site and wrong-patient procedures in the Universal Protocol era: analysis of a prospective database of physician self-reported occurrences. Arch Surg. 2010;145(10): 978-984. 10. Dimick JB, Chen SL, Taheri PA, Henderson WG, Khuri SF, Campbell DA Jr. Hospital costs associated with surgical complications: a report from the privatesector National Surgical Quality Improvement Program. J Am Coll Surg. 2004;199(4):531-537. 11. Eappen S, Lane BH, Rosenberg B, et al. Relationship between occurrence of surgical complications and hospital finances. JAMA. 2013;309(15):1599-1606. 12. 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(5):491-499. 13. Gawande AA, Zinner MJ, Studdert DM, Brennan TA. Analysis of errors reported by surgeons at three teaching hospitals. Surgery. 2003;133(6):614-621. 14. Lingard L, Reznick R, Espin S, Regehr G, DeVito I. Team communications in the operating room: talk patterns, sites of tension, and implications for novices. Acad Med. 2002;77(3):232-237. 15. Gardezi F, Lingard L, Espin S, Whyte S, Orser B, Baker GR. Silence, power and communication in the operating room. J Adv Nurs. 2009;65(7):1390-1399.

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16. Kohn LT, Corrigan JM, Donaldson MS, eds. To Err is Human: Building a Safer Health System. Washington, DC: The National Academies Press; 2000. http://www.nap.edu/ catalog.php?record_id¼9728. Accessed September 13, 2013. 17. Leape LL, Berwick DM, Bates DW. What practices will most improve safety? Evidence-based medicine meets patient safety. JAMA. 2002;288(4):501-507. 18. Lingard L, Espin S, Rubin B, Whyte S, et al. Getting teams to talk: development and pilot implementation of a checklist to promote interprofessional communication in the OR. Qual Saf Health Care. 2005;14(5): 340-346. 19. Safe Surgery Saves Lives. World Health Organization. http://www.who.int/patientsafety/safesurgery/en/index .html. Accessed October 25, 2013. 20. de Vries EN, Hollmann MW, Smorenburg SM, Gouma DJ, Boermeester MA. Development and validation of the SURgical PAtient Safety System (SURPASS) checklist. Qual Saf Health Care. 2009;18(2):121-126. 21. Semel ME, Resch S, Haynes AB, et al. Adopting a surgical safety checklist could save money and improve the quality of care in U.S. hospitals. Health Aff (Millwood). 2010;29(9):1593-1599. 22. Surgical safety web map. World Health Organization. http://maps.cga.harvard.edu:8080/Hospital. Accessed September 13, 2013. 23. Gawande A. The Checklist Manifesto: How to Get Things Right. New York, NY: Metropolitan Books of Henry Holt and Company; 2010. 24. Haynes AB, Weiser TG, Berry WR, et al. Changes in safety attitude and relationship to decreased postoperative morbidity and mortality following implementation of a checklist-based surgical safety intervention. BMJ Qual Saf. 2011;20(1):102-107. 25. Borchard A, Schwappach DL, Barbir A, Bezzola P. A systematic review of the effectiveness, compliance, and critical factors for implementation of safety checklists in surgery. Ann Surg. 2012;256(6):925-933. 26. Fineout-Overholt E, Melnyk BM, Stillwell SB, Williamson KM. Evidence-based practice step by step: critical appraisal of the evidence: part I. Am J Nurs. 2010; 110(7):47-52. 27. Calland JF, Turrentine FE, Guerlain S, et al. The surgical safety checklist: lessons learned during implementation. Am Surg. 2011;77(9):1131-1137. 28. Lingard L, Whyte S, Espin S, Baker GR, Orser B, Doran D. Towards safer interprofessional communication: constructing a model of “utility” from preoperative team briefings. J Interprof Care. 2006;20(5):471-483. 29. 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(5):660-666. 30. Vogts N, Hannam JA, Merry AF, Mitchell SJ. Compliance and quality in administration of a surgical safety checklist in a tertiary New Zealand hospital. N Z Med J. 2011;124(1342):48-58. 31. Yuan CT, Walsh D, Tomarken JL, Alpern R, Shakpeh J, Bradley EH. Incorporating the World Health Organization Surgical Safety Checklist into practice at two hospitals in Liberia. Jt Comm J Qual Patient Saf. 2012; 38(6):254-260.

136 j AORN Journal

McDOWELLdMcCOMB 32. Lingard L, Regehr G, Orser B, et al. Evaluation of a preoperative checklist and team briefing among surgeons, nurses, and anesthesiologists to reduce failures in communication. Arch Surg. 2008;143(1):12-17. 33. Kearns RJ, Uppal V, Bonner J, Robertson J, Daniel M, McGrady EM. The introduction of a surgical safety checklist in a tertiary referral obstetric centre. BMJ Qual Saf. 2011;20(9):818-822. 34. de Vries EN, Prins HA, Bennink C, et al. Nature and timing of incidents intercepted by the SURPASS checklist in surgical patients. BMJ Qual Saf. 2012;21(6): 503-508. 35. Berrisford RG, Wilson IH, Davidge M, Sanders D. Surgical time out checklist with debriefing and multidisciplinary feedback improves venous thromboembolism prophylaxis in thoracic surgery: a prospective audit. Eur J Cardiothorac Surg. 2012;41(6):1326-1329. 36. Askarian M, Kouchak F, Palenik CJ. Effect of surgical safety checklists on postoperative morbidity and mortality rates, Shiraz, Faghihy Hospital, a 1-year study. Qual Manag Health Care. 2011;20(4):293-297. 37. Kasatpibal N, Senaratana W, Chitreecheur J, Chotirosniramit N, Pakvipas P, Junthasopeepun P. Implementation of the World Health Organization surgical safety checklist at a university hospital in Thailand. Surg Infect (Larchmt). 2012;13(1):50-56. 38. de Vries EN, Eikens-Jansen MP, Hamersma AM, Smorenburg SM, Gouma DJ, Boermeester MA. Prevention of surgical malpractice claims by use of a surgical safety checklist. Ann Surg. 2011;253(3):624-628. 39. Einav Y, Gopher D, Kara I, et al. Preoperative briefing in the operating room: shared cognition, teamwork, and patient safety. Chest. 2010;137(2):443-449. 40. Ali M, Osborne A, Bethune R, Pullyblank A. Preoperative surgical briefings do not delay operating room start times and are popular with surgical team members. J Patient Saf. 2011;7(3):139-143. 41. Helmi€ o P, Blomgren K, Takala A, Pauniaho SL, Takala RS, Ikonen TS. Towards better patient safety: WHO Surgical Safety Checklist in otolaryngology. Clin Otolaryngol. 2011;36(3):242-247. 42. Takala RS, Pauniaho S, Korkansalo A, et al. A pilot study of the implementation of WHO surgical checklist in Finland: improvements in activities and communication. Acta Anaesthesiol Scand. 2011;55(10): 1206-1214. 43. B€ ohmer AB, Wappler F, Tinschmann T, et al. The implementation of a perioperative checklist increases patients’ perioperative safety and staff satisfaction. Acta Anaesthesiol Scand. 2012;56(3):332-338. 44. Nilsson L, Lindberget O, Gupta A, Vegfors M. Implementing a pre-operative checklist to increase patient safety: a 1-year follow-up of personnel attitudes. Acta Anaesthesiol Scand. 2010;54(2):176-182. 45. Papaspyros SC, Javangula KC, Adluri RK, O’Regan DJ. Briefing and debriefing in the cardiac operating room. Analysis of impact on theatre team attitude and patient safety. Interact Cardiovasc Thorac Surg. 2010;10(1): 43-47. 46. Thomassen Ø, Brattebø G, Heltne JK, Søfteland E, Espeland A. Checklists in the operating room: help or hurdle? A qualitative study on health workers’

SAFETY CHECKLIST BRIEFINGS experiences. BMC Health Serv Res. 2010;10(342). http:// www.biomedcentral.com/1472-6963/10/342. Accessed September 18, 2013. 47. Bandari J, Schumacher K, Simon M, et al. Surfacing safety hazards using standardized operating room briefings and debriefings at a large regional medical center. Jt Comm J Qual Patient Saf. 2012;38(4):154-160. 48. Melnyk B, Fineout-Overholt E. Evidence-Based Practice in Nursing & Healthcare. Philadelphia, PA: Lippincott, Williams & Wilkins; 2005.

Diana Soule McDowell, MSN, RN, CNOR, CPHQ, is a practitioner quality specialist at Indiana University Health North Hospital in Carmel and a doctor of nursing practice student

www.aornjournal.org

at Purdue University, West Lafayette, IN. Ms McDowell has no declared affiliation that could be perceived as posing a potential conflict of interest in the publication of this article. Sara A. McComb, PhD, PE, is an associate professor at the Schools of Nursing and Industrial Engineering at Purdue University, West Lafayette, IN. Dr McComb has no declared affiliation that could be perceived as posing a potential conflict of interest in the publication of this article.

AORN Journal j 137

Authors Askarian M (2011)1

Country Iran

Location Teaching tertiary hospital

Study design and evidence level

Checklist World Health Organization (WHO) Surgical Safety Checklist

n

n

Berrisford R (2012)2

United Kingdom

1 hospital

Adapted WHO Surgical Safety Checklist

n n

Calland J (2011)3,a

United States

Teaching tertiary hospital

Specific checklist developed for laparoscopic cholecystectomies

n n n

The Teaching Netherlands tertiary hospital

de Vries E (2012)5,b

The 2 academic Netherlands and 4 teaching tertiary hospitals

The SURgical PAtient Safety System (SURPASS) prototype checklist The SURPASS Checklist

n n

n n

n

n

Prospective audit of thoracic procedures Level VI

n

Randomized controlled trial Observations with and without checklist use Level II

n

Observational study Level VI

n

Self-report by checklist users Compliance measured by number of completed checklist items Level VI

n

n

Significant results

Preimplementation N ¼ 144 Postimplementation N ¼ 150

Compliance with completion of 7 checklist items pre-post implementation; total compliance achieved or maintained n Sign-in checklist: n Pulse oximeter in place: 97.2% n Risk for > 500 mL blood loss: 97.9% n Time-out checklist: n Anesthesia concerns: 98.6% n Essential images displayed: 100%

N ¼ 990

Compliance with completion of checklist items postimplementation n Time out performed: 96% n Most errors detected: venous thromboembolism prophylaxis missed: n ¼ 53 N ¼ 47 (n ¼ 23 in the n Significant positive results for elements in control group, n ¼ 24 the checklist cohort (all P < .001) in the checklist group) n Team introductions n Patient case presentation n Roles/responsibilities n Contingency planning N ¼ 171 procedures Observed process deviations corresponding to checklist items n Preoperative: 37.3% n Intraoperative: 42.2% N ¼ 6,313 procedures Compliance with completion of checklist items (approximately 1,000 postimplementation checklists from each of n Overall: 72.2% n Preoperative: 82.5% the 6 hospitals) n Intraoperative: 82.9%

McDOWELLdMcCOMB

de Vries E (2009)4

Pre-post implementation; compliance measured by checklist items completed for all elective general surgery procedures Level IV

Number

January 2014 Vol 99 No 1

137.e1 j AORN Journal

SUPPLEMENTARY TABLE 1. Compliance in Performing Briefings and Completing Checklists

Authors

Country

Kasatpibal N Thailand (2012)6

Location Teaching hospital

Study design and evidence level

Checklist The WHO Surgical Safety Checklist

n

n

n

Kearns R (2011)7,a

Scotland

Royal Hospital

A checklist developed by investigators and team members adapted for obstetrics

n n n n

Lingard L (2006)8

Canada

Teaching hospital

Not specified

n

n

Canada

Teaching tertiary hospital

Checklist developed by investigators

n n n n

Significant results

Prospective study, self-reports of compliance or variation by circulating nurses Compliance measured by completed checklist steps Level VI Observation of elective cesarean deliveries Postimplementation Compliance evaluated at 3 and 12 months Level VI Observational; the ethnographic field notes method was used to measure for informational and functional utility of briefings Level VI

n

N ¼ 4,340 procedures Compliance with completion of checklist steps in obstetrics and gypostimplementation necology, general, and n Verification of patient name: 96.0% orthopedic specialties n Verification of incision site: 95.7% n Verification of procedure: 95.9%

n

Preintervention N ¼ 34 procedures Postintervention N ¼ 59 procedures

Compliance with completion of checklist items postimplementation n 3 months: 61.2% n 12 months: 79.7%

n

N ¼ 302 cases

Observational Preintervention (5 months) Postintervention (5 months) Level IV

n

Preintervention N ¼ 86 procedures Postintervention N ¼ 86 procedures

Informational utility types observed: n Provision of new information (eg, operative plan, patient’s history) n Explicit conformations (eg, allergies, medications, blood products) n Reminders (eg, confirmations of known information) n Education Functional utility types observed: n Direct communications n Identification of problems or ambiguities n Prompting for decision making and planning n Provoking follow-up actions Observed communication failures n Mean of failures preintervention: 3.95 n Mean of failures postintervention: 1.31 (P < .001)

n

n

(table continued)

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AORN Journal j 137.e2

Lingard L (2008)9,a

Number

SAFETY CHECKLIST BRIEFINGS

SUPPLEMENTARY TABLE 1. (continued ) Compliance in Performing Briefings and Completing Checklists

Authors Mainthia R (2012)10

Country United States

Location Teaching tertiary hospital

Study design and evidence level

Checklist An electronic checklist

n n

n

n

Vogts N (2011)11

New Zealand

City hospital

The WHO Surgical Safety Checklist

n

n

Direct observational Preintervention (1 month before implementation) and postintervention (1 month and 9 months after implementation) The existing practice was to only document that the time out had been performed Level VI

n

Observational prospective study of mixed specialties performed 2 years after checklist initiation Compliances rated in 3 separate time periods over 2 months Level IV

n

n

n

Significant results

Preintervention N ¼ Compliance with completion of checklist items 80 procedures postimplementation Postintervention N ¼ n Overall: 36.1% increase in time-out 160 procedures, 80 compliance procedures at 1 Mean compliance of core items month, 80 procedures n Preintervention: 49.7%  12.9% n Postintervention at 1 month: 81.6%  at 9 months 11.4% n Postintervention at 9 months: 85.8%  6.8% Improvement in compliance with elements of time out (P < .0001) n Presence of required team members n Presence of person who marked the site n Patient identity verified n Surgical site marking n Relevant images present n Availability of blood products n Antibiotic administration verified n Discussion of relevant special considerations Sign in N ¼ 99 Compliance with completion of checklist items procedures postimplementation Time out N ¼ 94 n Sign in: n Patient identity: 100% procedures n Surgical site stated/agreed: 94% n Surgical site marked: 33% n Procedure stated/agreed: 99% n Consent stated/verified: 96% n Allergy stated: 95% n Time out: n Team members introduction: 74% n Patient identity stated/agreed: 100% n Surgical site stated/agreed: 100%

McDOWELLdMcCOMB

n

Number

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137.e3 j AORN Journal

SUPPLEMENTARY TABLE 1. (continued ) Compliance in Performing Briefings and Completing Checklists

Authors

Country

Location

Study design and evidence level

Checklist

Number

Significant results n n

n

Yuan C (2012)12,b

Liberia

1 community Adapted the WHO and 1 Surgical Safety governChecklist ment referral

n n n n

Observational; Pre-post intervention (2 months each) Comparison of 2 hospitals Level IV

n n

Preintervention N ¼ 232 cases Postintervention N ¼ 249 cases

Procedure stated/agreed: 100% Surgeon enumerates/denies any anticipated critical event: 90% Anesthetist enumerates/denies any anticipated critical events: 78%

Compliance with completion of 4 or more checklist items pre-post implementation n Pooled ORs: n Preimplementation: 58.6% n Postimplementation: 80.7% (P < .0001) n Hospital 1 (community) OR: n Preimplementation: 46.2% n Postimplementation: 77.7% (P < .0001) n Hospital 2 (government referral) OR: n Preimplementation 72.2% (P ¼ .112) n Postimplementation: 83.1% (P ¼ .112)

SAFETY CHECKLIST BRIEFINGS

SUPPLEMENTARY TABLE 1. (continued ) Compliance in Performing Briefings and Completing Checklists

a See also perceptions results in Supplementary Table 3. b See also outcomes results in Supplementary Table 2. Level II ¼ randomized controlled trial; Level IV ¼ case-control or cohort study; Level VI ¼ qualitative or descriptive study.

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AORN Journal j 137.e4

1. Askarian M, Kouchak F, Palenik CJ. Effect of surgical safety checklists on postoperative morbidity and mortality rates, Shiraz, Faghihy Hospital, a 1-year study. Qual Manag Health Care. 2011;20(4):293-297. 2. Berrisford RG, Wilson IH, Davidge M, Sanders D. Surgical time out checklist with debriefing and multidisciplinary feedback improves venous thromboembolism prophylaxis in thoracic surgery: a prospective audit. Eur J Cardiothorac Surg. 2012;41(6):1326-1329. 3. Calland JF, Turrentine FE, Guerlain S, et al. The surgical safety checklist: lessons learned during implementation. Am Surg. 2011;77(9):1131-1137. 4. de Vries EN, Hollmann MW, Smorenburg SM, Gouma DJ, Boermeester MA. Development and validation of the SURgical PAtient Safety System (SURPASS) checklist. Qual Saf Health Care. 2009;18(2):121-126. 5. de Vries EN, Prins HA, Bennink C, et al. Nature and timing of incidents intercepted by the SURPASS checklist in surgical patients. BMJ Qual Saf. 2012;21(6):503-508. 6. Kasatpibal N, Senaratana W, Chitreecheur J, Chotirosniramit N, Pakvipas P, Junthasopeepun P. Implementation of the World Health Organization surgical safety checklist at a university hospital in Thailand. Surg Infect (Larchmt). 2012;13(1):50-56. 7. Kearns RJ, Uppal V, Bonner J, Robertson J, Daniel M, McGrady EM. The introduction of a surgical safety checklist in a tertiary referral obstetric centre. BMJ Qual Saf. 2011;20(9):818-822. 8. Lingard L, Whyte S, Espin S, Baker GR, Orser B, Doran D. Towards safer interprofessional communication: constructing a model of “utility” from preoperative team briefings. J Interprof Care. 2006;20(5):471-483. 9. Lingard L, Regehr G, Orser B, et al. Evaluation of a preoperative checklist and team briefing among surgeons, nurses, and anesthesiologists to reduce failures in communication. Arch Surg. 2008;143(1):12-17. 10. 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(5):660-666. 11. Vogts N, Hannam JA, Merry AF, Mitchell SJ. Compliance and quality in administration of a surgical safety checklist in a tertiary New Zealand hospital. N Z Med J. 2011;124(1342):48-58. 12. Yuan CT, Walsh D, Tomarken JL, Alpern R, Shakpeh J, Bradley EH. Incorporating the World Health Organization Surgical Safety Checklist into practice at two hospitals in Liberia. Jt Comm J Qual Patient Saf. 2012;38(6):254-260.

Authors Ali M (2011)1,a

Country England

Location 2 teaching hospitals

Checklist The World Health Organization (WHO) Surgical Safety Checklist

Study design n

n

Askarian M (2011)2,b

Iran

Teaching tertiary hospital

The WHO Surgical Safety Checklist

n

n

de Vries E (2012)3,b

The Netherlands

2 academic and 4 teaching tertiary hospitals

The SURgical PAtient Safety System (SURPASS) Checklist

de Vries E (2011)4

The Netherlands

Teaching tertiary hospital

The SURPASS Checklist

n

n n

Einav Y (2010)5,a

Israel

Teaching tertiary hospital

Not specified

n

Observational prepost intervention blinded

n n

n n

Significant results

Preintervention N ¼ 27 procedures Postintervention N ¼ 34 procedures

Comparison of start times n xc start time: 30.7 (SD 19.3) n xcl start time: 23.5 (SD 14.5) n No statistical significance at P ¼ .01

Preintervention N ¼ 144 Postintervention N ¼ 150

Any complications n Preintervention: 22.9% n Postintervention: 10% (P ¼ .03)

N ¼ 6,313 cases (approximately 1,000 checklists from each of the 6 hospitals)

Intercepted incidents n Total: 6,312 n Preoperative: 3,458 (54.8%) n Perioperative: 897 (14.2%)

N ¼ 294 claims

Contributing factors to critical outcomes corresponding to SURPASS checklist n Overall n Preoperative: 69% n Perioperative: 15% n Specific types of Incidents n Perioperative human error: 20% n Wrong side/site/procedure/patient: 16% n Technical/equipment/implant: 5% n Retained instrument/gauze: 4%

n

Preintervention N ¼ 130 procedures

Results of observations n Surgeries without any nonroutine events increased by 16%

McDOWELLdMcCOMB

n

Pre-post intervention studies for effect on OR start times and team evaluations Level IV Pre-post implementation for elective general surgery procedures Level IV Self-report by checklist users measuring intercepted incidents as a result of adherence to the checklist Level VI Retrospective closed claims review; contributing factors in claims compared with items on the SURPASS Checklist Level VI

Number

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137.e5 j AORN Journal

SUPPLEMENTARY TABLE 2. Outcomes Associated With Checklist Briefings

Authors

Country

Location

Checklist

Study design

n

n

Yuan C (2012)6,b

Liberia

1 community and 1 government referral

Adapted WHO Surgical Safety Checklist

n n n n

Number

examinations of nonroutine events (3 months each) Outcomes measured related to nonroutine events during procedures Level IV

n

Postintervention N ¼ 102 procedures

Observational Preintervention (2 months) Postintervention (2 months) Level IV

n

Preintervention N ¼ 232 procedures Postintervention N ¼ 249 procedures

n

Significant results n

Surgeries with 1 to 2 nonroutine events reduced by 5% n Surgeries with 3 or more nonroutine events reduced by 11% (P < .02) n xc nonroutine events: 2.1 n xcl nonroutine events: 1.6 (P < .004) when 25% of items were completed n xcl nonroutine events: 1.45 when > 40% of items completed Results of observations pre-post intervention Outcomesdsurgical site infection (SSI) n Pooled ORs: n Preintervention: 28.6% n Postintervention: 9.9% (P ¼ .0001) n Hospital 1 (community) OR: n Preintervention: 13.1% n Postintervention: 9.6% (P ¼ .506) n Hospital 2 (government referral) OR: n Preintervention: 43.4% n Postintervention: 10.1% (P < .0001)

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AORN Journal j 137.e6

Outcomes: any complication n Pooled ORs: n Preintervention: 32.9% n Postintervention: 19.1% (P ¼ .005) n Hospital 1 ( community) OR: n Preintervention: 16.2% n Postintervention: 13.6% (P ¼ .488) (table continued)

SAFETY CHECKLIST BRIEFINGS

SUPPLEMENTARY TABLE 2. (continued ) Outcomes Associated With Checklist Briefings

Authors

Country

Location

Checklist

Study design

Number

Significant results n

Hospital 2 (government referral) OR: n Preintervention: 50.0% n Postintervention: 23.2% (P ¼ .008)

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137.e7 j AORN Journal

SUPPLEMENTARY TABLE 2. (continued ) Outcomes Associated With Checklist Briefings

a See also perception results in Supplementary Table 3. b See also compliance results in Supplementary Table 1. xc ¼ Mean of control or preintervention cohort; xcl ¼ mean of checklist or postintervention cohort; Level IV ¼ case-control or cohort study; Level VI ¼ qualitative or descriptive study. 1. 2. 3. 4. 5. 6.

Ali M, Osborne A, Bethune R, Pullyblank A. Preoperative surgical briefings do not delay operating room start times and are popular with surgical team members. J Patient Saf. 2011;7(3):139-143. Askarian M, Kouchak F, Palenik CJ. Effect of surgical safety checklists on postoperative morbidity and mortality rates, Shiraz, Faghihy Hospital, a 1-year study. Qual Manag Health Care. 2011;20(4):293-297. de Vries EN, Prins HA, Bennink C, et al. Nature and timing of incidents intercepted by the SURPASS checklist in surgical patients. BMJ Qual Saf. 2012;21(6):503-508. de Vries EN, Eikens-Jansen MP, Hamersma AM, Smorenburg SM, Gouma DJ, Boermeester MA. Prevention of surgical malpractice claims by use of a surgical safety checklist. Ann Surg. 2011;253(3):624-628. Einav Y, Gopher D, Kara I, Ben-Yosef O, et al. Preoperative briefing in the operating room: shared cognition, teamwork, and patient safety. Chest. 2010;137(2):443-449. Yuan CT, Walsh D, Tomarken JL, Alpern R, Shakpeh J, Bradley EH. Incorporating the World Health Organization Surgical Safety Checklist into practice at two hospitals in Liberia. Jt Comm J Qual Patient Saf. 2012;38(6):254-260.

McDOWELLdMcCOMB

Authors

Country

Ali M (2011)1,a England

Location 2 teaching hospitals

Checklist The World Health Organization (WHO) Surgical Safety Checklist

Study design n

n

Bandari J (2012)2

United States

Teaching tertiary hospital

Not specified, similar to WHO Surgical Safety Checklist

n

n

€hmer A Bo (2012)3

Germany

Academic

Not specified, similar to WHO Surgical Safety Checklist

n

n n

United States

Teaching tertiary hospital

Specific checklist developed for

n

Staff satisfaction surveys postintervention (2 months) after briefing being added to existing checklist Level VI

n

Postimplementation team surveys on effectiveness of briefings Level VI

n

Pre-post intervention (3 months) checklist implementation Cross-sectional surveys (Likert 1-5) Level IV

n

Postintervention procedure surveys (Likert scale 1-5; case difficulty 1 is

n

Significant results

N ¼ 37 team members Team survey resultsdpositive responses n Briefing increased staff awareness of the procedure: 89% n Briefing highlighted potential patient problems: 97% n Briefing made staff members feel more a part of the team: 62% n Would like team briefings to continue: 97% n Briefings/debriefings improved communication: 89% N ¼ 40 team members Team survey resultsdpositive responses n Overall, briefings were effective for surfacing defects: 87% n Briefings were effective in identifying operational defects: 83% n Briefings were effective in identifying defects in clinical care: 93% N ¼ 71 team members Team survey resultsdsignificant positive responses across disciplines n Knowledge of other team members: anesthesiologists: significance (P < .05) n Knowledge of patient’s identity: trauma team: significance (P < .05) n Knowledge of procedure: trauma team: significance (P < .001 ) n Knowledge of high-risk patients: trauma team: significance (P < .05) n Belief that OR teamwork is excellent: anesthesiologists: significance (P < .001) Control N ¼ 142 pro- Responses from team surveys in median cedures/survey scores responses (table continued)

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AORN Journal j 137.e8

Calland J (2011)4,b

Number

SAFETY CHECKLIST BRIEFINGS

SUPPLEMENTARY TABLE 3. Perceptions Regarding the Use of Checklist Briefings

Authors

Country

Location

Checklist

Study design

laparoscopic cholecystectomies

n

n

Einav Y (2010)5,a

Haynes A (2011)6

Israel

Teaching tertiary hospital

n n

The WHO Surgical Safety Checklist

n n

n n

easy, 5 is hard; comfort level 1 is at ease, 5 is uncomfortable; team efficiency and communication 1 is very satisfied, 5 is not satisfied at all) Procedural experiences and situational awareness performed in each group Level VI

n

Postintervention survey (Likert 1-5) Level VI

n

Pre-post intervention study (2 weeks each) Modified to OR Safety Attitudes Questionnaire (SAQ) Scale 1-5, 5 being better safety attitude Level IV

n n

Significant results

Checklist N ¼ 139 procedures/survey responses

n

Preintervention N ¼ 281 team members Postintervention N ¼ 257 team members

Team survey resultsdpositive responses n Checklist is easy to use: 80.2% n Checklist improved OR safety: 80.2% n Communication improved through use of the checklist: 84.8% n Checklist helped prevent errors in the OR: 78.6% Preintervention and postintervention SAQ score results n xc: 3.91 n xcl: 4.01 (P ¼ .0127)

Control: procedures were more difficult: 2 n Checklist: procedures were more difficult: 2 (P ¼ .0065) n Control: comfort level 1 n Checklist: comfort level 2 (P ¼ .0335) n Control: team efficiency 1 n Checklist: team efficiency 2 (P ¼ .0002) n Control: team communication 1 n Checklist: team communication 1 (P ¼ .0370) n Situational awareness: composite scores for team members were higher in checklist cohort but not significantly N ¼ 32 team members Team survey resultsdpositive responses to the 3-question survey n Value of briefings with respect to n their own work: > 4.0 n the team’s work: > 4.0 n patient safety: > 4.0

McDOWELLdMcCOMB

Canada, In8 hospitals dia, Jordan, New Zealand, Philippines, Tanzania, United Kingdom, United States

Not specified

Number

January 2014 Vol 99 No 1

137.e9 j AORN Journal

SUPPLEMENTARY TABLE 3. (continued ) Perceptions Regarding the Use of Checklist Briefings

Authors €P Helmio (2011)7

Country Finland

Location Teaching tertiary hospital

Checklist The WHO Surgical Safety Checklist

Study design n

n

n

Kearns R (2011)8,b

Scotland

Royal Hospital

Checklist developed by investigators and team members adapted for obstetrics

n

n

Pre-post intervention (1 month each) implementation Cross-sectional study between surgeons, anesthesiologists, and nurses Level IV

n

Pre-post intervention team survey in an obstetric OR for elective Cesarean deliveries Cross-sectional comparison between medical and nonmedical team members Level IV

n

n

n

Preintervention N ¼ 288 procedures/survey responses Postintervention N ¼ 412 procedures/survey responses

Significant results Overall positive responses related to teamwork n Improved knowledge of team members’ names and roles, improved discussion of risks n Surgeons/anesthesiologists: P < .001 n Nurses: nonsignificant n Successful communication n Surgeons: nonsignificant n Anesthesiologists: P ¼ .0064 n Nurses: P < .001 n Improved identity of patient n All respondents: P < .001 n Knowledge of procedure n Surgeons: P ¼ .0015 n Anesthesiologists P ¼ .0085 n Nurses: nonsignificant n Improved knowledge of patient’s history, medications, and allergies n Anesthesiologists: P < .001 n Others: nonsignificant

Preintervention N ¼ 53 Team survey results postimplementation n Felt familiar with team members team members Postintervention N ¼ n Medical: 30.8% n Nonmedical: 75% (P ¼ .003) 46 team members n Communication had improved n Medical: 57.7% n Nonmedical: 85% (P ¼ .046) n Checklist useful in elective procedures n Medical: 73.1% n Nonmedical: 90% (P ¼ .262) (table continued)

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AORN Journal j 137.e10

n

Number

SAFETY CHECKLIST BRIEFINGS

SUPPLEMENTARY TABLE 3. (continued ) Perceptions Regarding the Use of Checklist Briefings

Authors Lingard L (2008)9,b

Country Canada

Location Teaching tertiary hospital

Checklist Checklist designed by investigators

Study design n

n

Nilsson L (2010)10

Sweden

2 hospitals

Locally developed checklist

n n n

Papaspyros S (2010)11

England

n n n n

5 months postintervention survey to team members who had participated in at least 2 checklist briefings Level VI

n

1 year postimplementation Team member surveys Level VI

n

Qualitative Team interviews Postimplementation after the first 188 surgeries Level VI

n

Significant results

N ¼ 77 team members Survey responses n Checklist gave patient and procedure information that would not have been made available otherwise: 69% n Gave the team the opportunity to identify and resolves problems: 92% n Gave an educational opportunity: 78% n Potential to guard against mistakes in the OR: 88% n Strengthens OR team: 73% n Checklist discussions worthwhile: 81% N ¼ 331 team Team survey resultsdpositive responses n Checklist gave patient and procedure members information that would not have been made available otherwise: 27% n Gave the team the opportunity to identify and resolve problems: 86% n Gave an educational opportunity: 57% n Potential to guard against mistakes in the OR: 97% n Strengthens the OR team: 65% n Adds to patient safety: 93% n Helps solve problems: 86% N ¼ 15 team members Team survey results measured in adjectives n Team member identities and roles: 10 responses n Confidence: 2 responses n Patient focused: 11 responses n Valued: 4 responses n Common goal: 4 responses n Blame-free: 5 responses n Communication: 6 responses n Opinions and feedback: 10 responses

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Cardiac ORs Safety briefing tool in 1 teachadapted for cardiac ing hospiORs tal and 1 small private hospital

Number

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SUPPLEMENTARY TABLE 3. (continued ) Perceptions Regarding the Use of Checklist Briefings

Authors

Country

Location

Checklist

Study design

Number

Significant results n

Takala R (2011)12

Finland

Adapted WHO Surgical Preintervention and postSafety Checklist intervention (4 weeks preintervention and 6 weeks postintervention) checklist implementation n Staff satisfaction survey n Cross section of surgeons, anesthesiologists, and nurses n Level IV

Tertiary teaching hospital

Preinduction checklist developed by anesthesia professionals

n n

n

Qualitative study Cross-sectional focus groups at 1 and 5 months postfinal version of checklist Level VI

n

n

n

Preintervention N ¼ 901 procedures/survey responses Postintervention N ¼ 847 procedures/survey responses

N ¼ 14 team members

n

Team survey results described by the following responses n The checklist could divert attention away from the patient. n The checklist influenced workflow and physician-nurse cooperation. (table continued)

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Norway Thomassen Ø (2010)13

4 university and teaching hospitals

Morale and professionalism: 8 responses n Team focus: 8 responses Team survey results: pre-post implementation n Improved patient identity (all significant at P < .01) n Nurse: 81.6%/94.2% n Anesthesiologist: 62.7%/84% n Surgeon: 71.6%/85.5% n Knowledge of surgery n Nurse: 94.7%/96% (nonsignificant) n Anesthesiologist: 87.1%/90.6% (nonsignificant) n Surgeon: 85.2%/93.2% (P < .01) n Improved knowledge of team members’ names and roles (all significant at P < .01) n Nurse: 87.7%/93.2% n Anesthesiologist: 65.7%/81.8% n Surgeon: 71.1%/83.6% n Communication n Nurse: 88.7%/98.1% (P < .01) n Anesthesiologist: 89.3%/93.7% (P < .05) n Surgeon: 96.8%/97.4% (nonsignificant)

SAFETY CHECKLIST BRIEFINGS

SUPPLEMENTARY TABLE 3. (continued ) Perceptions Regarding the Use of Checklist Briefings

Authors

Country

Location

Checklist

Study design

Number

Significant results n

n

The checklist improved confidence in unfamiliar contexts (eg, out of the department). The checklist identified insufficient equipment standardization.

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SUPPLEMENTARY TABLE 3. (continued ) Perceptions Regarding the Use of Checklist Briefings

a See also outcomes results in Supplementary Table 2. b See also compliance results in Supplementary Table 1. xc ¼ mean of control or pre-intervention cohort; Level IV ¼ case-control or cohort study; Level VI ¼ qualitative or descriptive study. 1. Ali M, Osborne A, Bethune R, Pullyblank A. Preoperative surgical briefings do not delay operating room start times and are popular with surgical team members. J Patient Saf. 2011;7(3):139-143. 2. Bandari J, Schumacher K, Simon M, et al. Surfacing safety hazards using standardized operating room briefings and debriefings at a large regional medical center. Jt Comm J Qual Patient Saf. 2012;38(4):154160. €hmer AB, Wappler F, Tinschmann T, et al. The implementation of a perioperative checklist increases patients’ perioperative safety and staff satisfaction. Acta Anaesthesiol Scand. 2012;56(3):332-338. 3. Bo 4. Calland JF, Turrentine FE, Guerlain S, et al. The surgical safety checklist: lessons learned during implementation. Am Surg. 2011;77(9):1131-1137. 5. Einav Y, Gopher D, Kara I, Ben-Yosef O, et al. Preoperative briefing in the operating room: shared cognition, teamwork, and patient safety. Chest. 2010;137(2):443-449. 6. Haynes AB, Weiser TG, Berry WR, et al. Changes in safety attitude and relationship to decreased postoperative morbidity and mortality following implementation of a checklist-based surgical safety intervention. BMJ Qual Saf. 2011;20(1):102-107. € P, Blomgren K, Takala A, Pauniaho SL, Takala RS, Ikonen TS. Towards better patient safety: WHO Surgical Safety Checklist in otolaryngology. Clin Otolaryngol. 2011;36(3):242-247. 7. Helmio 8. Kearns RJ, Uppal V, Bonner J, Robertson J, Daniel M, McGrady EM. The introduction of a surgical safety checklist in a tertiary referral obstetric centre. BMJ Qual Saf. 2011;20(9):818-822. 9. Lingard L, Regehr G, Orser B, et al. Evaluation of a preoperative checklist and team briefing among surgeons, nurses, and anesthesiologists to reduce failures in communication. Arch Surg. 2008;143(1):12-17. 10. Nilsson L, Lindberget O, Gupta A, Vegfors M. Implementing a pre-operative checklist to increase patient safety: a 1-year follow-up of personnel attitudes. Acta Anaesthesiol Scand. 2010;54(2):176-182. 11. Papaspyros SC, Javangula KC, Adluri RK, O’Regan DJ. Briefing and debriefing in the cardiac operating room. Analysis of impact on theatre team attitude and patient safety. Interact Cardiovasc Thorac Surg. 2010;10(1):43-47. 12. Takala RS, Pauniaho S, Korkansalo A, et al. A pilot study of the implementation of WHO surgical checklist in Finland: improvements in activities and communication. Acta Anaesthesiol Scand. 2011;55(10):12061214. 13. Thomassen Ø, Brattebø G, Heltne JK, Søfteland E, Espeland A. Checklists in the operating room: help or hurdle? A qualitative study on health workers’ experiences. BMC Health Serv Res. 2010;10:342. http:// www.biomedcentral.com/1472-6963/10/342. Accessed September 18, 2013.

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