Arvid Steinar Haugen

Impact of the World Health Organization's Surgical Safety Checklist on safety culture in the operating theatre: a controlled intervention study

Background Positive changes in safety culture have been hypothesized to be one of the mechanisms behind the reduction in mortality and morbidity after the introduction of the World Health Organizations Surgical Safety Checklist (SSC). We aimed to study the checklist effects on safety culture perceptions in operating theatre personnel using a prospective controlled intervention design at a single Norwegian university hospital. Methods We conducted a study with pre- and post-intervention surveys using the intervention and control groups. The primary outcome was the effects of the Norwegian version of the SSC on safety culture perceptions. Safety culture was measured using the validated Norwegian version of the Hospital Survey on Patient Safety Culture. Descriptive characteristics of operating theatre personnel and checklist compliance data were also recorded. A mixed linear regression model was used to assess changes in safety culture. Results The response rate was 61% (349/575) at baseline and 51% (292/569) post-intervention. Checklist compliance ranged from 77% to 85%. We found significant positive changes in the checklist intervention group for the culture factors ‘frequency of events reported’ and ‘adequate staffing’ with regression coefficients at −0.25 [95% confidence interval (CI), −0.47 to −0.07] and 0.21 (95% CI, 0.07–0.35), respectively. Overall, the intervention group reported significantly more positive culture scores—including at baseline. Conclusions Implementation of the SSC had rather limited impact on the safety culture within this hospital.

A survey of surgical team members' perceptions of near misses and attitudes towards Time Out protocols

BackgroundMedical errors are inherently of concern in modern health care. Although surgical errors as incorrect surgery (e.g., wrong patient, wrong site, or wrong procedure) are infrequent, they are devastating events to experience. To gain insight about incidents that could lead to incorrect surgery, we surveyed how surgical team members perceive near misses and their attitudes towards the use of Time Out protocols in the operating room. We hypothesised that perceptions of near-miss experiences and attitudes towards Time Out protocols vary widely among surgical team members.MethodsThis cross-sectional study (N = 427) included surgeons, anaesthetists, nurse anaesthetists, and operating room nurses. The questionnaire consisted of 14 items, 11 of which had dichotomous responses (0 = no; 1 = yes) and 3 of which had responses on an ordinal scale (never = 0; sometimes = 1; often = 2; always = 3). Items reflected team members’ experience of near misses or mistakes; their strategies for verifying the correct patient, site, and procedure; questions about whether they believed that these mistakes could be avoided using the Time Out protocol; and how they would accept the implementation of the protocol in the operating room.ResultsIn the operating room, 38% of respondents had experienced uncertainty of patient identity, 81% had experienced uncertainty of the surgical site or side, and 60% had prepared for the wrong procedure. Sixty-three per cent agreed that verifying the correct patient, site, and procedure should be a team responsibility. Thus, only nurse anaesthetists routinely performed identity checks prior to surgery (P ≤ 0.001). Of the surgical team members, 91% supported implementation of a Time Out protocol in their operating rooms.ConclusionThe majority of our surgical personnel experienced near misses with regard to correct patient identity, surgical site, or procedure. Routines for ensuring the correct patient, site, and surgical procedure must involve all surgical team members. We find that the near-miss experiences are a wake-up call for systematic risk reducing efforts and the use of checklists in surgery.

Adjusting team involvement: a grounded theory study of challenges in utilizing a surgical safety checklist as experienced by nurses in the operating room

BackgroundEven though the use of perioperative checklists have resulted in significant reduction in postoperative mortality and morbidity, as well as improvements of important information communication, the utilization of checklists seems to vary, and perceived barriers are likely to influence compliance. In this grounded theory study we aimed to explore the challenges and strategies of performing the WHO’s Safe Surgical Checklist as experienced by the nurses appointed as checklist coordinators.MethodsGrounded theory was used in gathering and analyzing data from observations of the checklist used in the operating room, in conjunction with single and focus group interviews. A purposeful sample of 14 nurse-anesthetists and operating room nurses as surgical team members in a tertiary teaching hospital participated in the study.ResultsThe nurses’ main concern regarding checklist utilization was identified as “how to obtain professional and social acceptance within the team”. The emergent grounded theory of “adjusting team involvement” consisted of three strategies; distancing, moderating and engaging team involvement. The use of these strategies explains how they resolved their challenges. Each strategy had corresponding conditions and consequences, determining checklist compliance, and how the checklist was used.ConclusionEven though nurses seem to have a loyal attitude towards the WHO’s checklist regarding their task work, they adjusted their surgical team involvement according to practical, social and professional conditions in their work environment. This might have resulted in the incomplete use of the checklist and therefore a low compliance rate. Findings also emphasized the importance of: a) management support when implementing WHO’s Safe Surgical Checklist, and b) interprofessional education approach to local adaptation of the checklists use.

Causal Analysis of World Health Organization's Surgical Safety Checklist Implementation Quality and Impact on Care Processes and Patient Outcomes: Secondary Analysis From a Large Stepped Wedge Cluster Randomized Controlled Trial in Norway

Objective: We hypothesize that high-quality implementation of the World Health Organizations Surgical Safety Checklist (SSC) will lead to improved care processes and subsequently reduction of peri- and postoperative complications. Background: Implementation of the SSC was associated with robust reduction in morbidity and length of in-hospital stay in a stepped wedge cluster randomized controlled trial conducted in 2 Norwegian hospitals. Further investigation of precisely how the SSC improves care processes and subsequently patient outcomes is needed to understand the causal mechanisms of improvement. Methods: Care process metrics are reported from one of our earlier trial hospitals. Primary outcomes were in-hospital complications and care process metrics, e.g., patient warming and antibiotics. Secondary outcome was quality of SSC implementation. Analyses include Pearsons exact &khgr;2 test and binary logistic regression. Results: A total of 3702 procedures (1398 control vs. 2304 intervention procedures) were analyzed. High-quality SSC implementation (all 3 checklist parts) improved processes and outcomes of care. Use of forced air warming blankets increased from 35.3% to 42.4% (P < 0.001). Antibiotic administration postincision decreased from 12.5% to 9.8%, antibiotic administration preincision increased from 54.5% to 63.1%, and nonadministration of antibiotics decreased from 33.0% to 27.1%. Surgical infections decreased from 7.4% (104/1398) to 3.6% (P < 0.001). Adjusted SSC effect on surgical infections resulted in an odds ratio (OR) of 0.52 (95% confidence interval (CI): 0.38–0.72) for intervention procedures, 0.54 (95% CI: 0.37–0.79) for antibiotics provided before incision, and 0.24 (95% CI: 0.11–0.52) when using forced air warming blankets. Blood transfusion costs were reduced by 40% with the use of the SSC. Conclusions: When implemented well, the SSC improved operating room care processes; subsequently, high-quality SSC implementation and improved care processes led to better patient outcomes.

Accuracy of surgical complication rate estimation using ICD-10 codes: Surgical complication rate estimation using ICD-10 codes

The ICD‐10 codes are used globally for comparison of diagnoses and complications, and are an important tool for the development of patient safety, healthcare policies and the health economy. The aim of this study was to investigate the accuracy of verified complication rates in surgical admissions identified by ICD‐10 codes and to validate these estimates against complications identified using the established Global Trigger Tool (GTT) methodology.

Preventing Complications: The Preflight Checklist

Compliance with the World Health Organisation Surgical Safety Checklist is associated with reduction of complications and mortality.