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THE SURGICAL SAFETY CHECKLIST
Dr Jacqueline Hannam
Associate Professor Simon Mitchell
Department of AnaesthesiologyUniversity of Auckland
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Complications after inpatient operations occur in up to 25% of patients
Reported crude mortality rate after major surgery is 0.5–5%
In industrialized countries, nearly half of all adverse events in hospitalized patients are related to surgical care, and at least half of these considered preventable
WHO SSC implemented at ACH in 2008 as part of the global pilot study (NEJM 2009;360:491-9)
Overall study outcome;Mortality pre vs post = 1.5 vs 0.8%Complications pre vs post = 11% vs 7%
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The checklist at Auckland
Benjamin A BMJ 2008;336:1241-1245
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Van Klei et al
What to audit? 1. Is it used?
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Increased odds of complication or death if information sharing was omitted or poor either intra-operatively or at patient
handover.
What to audit? 2. Is it used correctly?
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Compliance =
“verbal communication of that item by the checklist administrator or other OR team member during SSC
administration”
Engagement =
“Engagement was rated according to the number of OR teams engaged. At least one team member had to be
engaged in SSC administration for the team to be considered engaged, and engagement was defined as listening or contributing to SSC administration with
cessation of other activities and conversations.”
Definitions
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Retrospective note review:
Possibly prone to inaccuracies and may not represent actual checklist compliance
Cannot measure team engagement with process
Direct observation:
Time consuming and potentially costly, but preferred option
Method of measurement?
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• 41 SSC domains in two OR suites
• Observer rated compliance with domains and domain items using previous definitions
• Observer-rated compliance compared with self-reported compliance (boxes checked on SSC form in patient notes)
• Accuracy in documentation investigated using logistic regression analysis with adjustment for confounding factors (operating suite and SSC domain)
Accuracy of retrospective note review
Checking the checkers: an audit of self-reporting checklist use
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• Domain compliance recording accurate in 75% of domains
• Item compliance recording was accurate for 51% of items • Likelihood of accurate self-reporting greater for items that
were observed as being completed than for those that were not (OR 22.85, 95% CI 10.78-48.42, p<0.0001)
• Example - item compliance reported as 86% at Suite 1 (68% true positive + 18% false positive) versus 82% of items at Suite 2 (15% + 67%).
At face value these seem comparable BUT item compliance as rated by observers was 68% at Suite 1 and just 15% at Suite 2!
Checking the checkers - results
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Tendency to report compliance favourably when items are NOT completed
Reliance on self-reported rates of compliance with SSC is likely to grossly over-estimate true compliance
Big variation in observed compliance levels between OR suites within the same hospital, not detectable by retrospective note review
Inaccurate representation of checklist practices within centres could hinder attempts to identify areas where improvements could be made.
Checking the checkers - results
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Audit 1:Direct observation100 cases at ACH
Compliance with administration of
checklist domainsand domain items
TeamEngagement
Primary outcomes Secondary outcomes
2 months, 2010 – 2011 (2 years post checklist roll out)
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Domain complianceSign In: 99%Time out: 94 %Sign Out: 2 %
Item complianceMean (range)Sign In: 56% (27 – 100)Time out: 69% (33 – 100)Sign Out: NA
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Team engagement
Entire staff
3 teams 2 teams 1 team
Sign inn=99
0% 3% 52% 45%
Time outn=94
15% 38% 35% 12%
Sign outn=2
0% 0% 50% 50%
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Key findings of audit
• Sign In and Time Out are completed most of the time; including items that intuitively seem most important
• Sign out not being done!!
• Staff engagement sub-optimal
• A drift in administration standards appeared to have occurred since the study
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Interventions?
• Present findings to OR staff
• Feedback and discussions with group
“Sign Out is not linked to a specific event in patient management”
• Link Sign Out to the end of the swab & instrument count
…re-audit to assess the intervention
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Simultaneous audit of 100 cases at a study and a non-study hospital, 2011
Compliance with administration of
checklist domainsand domain items
TeamEngagement
Primary outcomes Secondary outcomes
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Compliance with domain administration
Hospital 1
Study hospital
Hospital 2
Sign in 96% 31%
Time out 99% 48%
Sign out 22% 9%
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Compliance with checklist item administration
Hospital 1
Study hospital
Hospital 2
Sign in 59% (3-100) 69% (3-100)
Time out 78% (15-100) 59% (2-98)
Sign out 74% (9-100) 44% (11-89)
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Team engagement
All staff 3 teams 2 teams 1 team
Hospital 1 2 1 2 1 2 1 2
Sign in 0% 0% 1% 0% 39% 75% 60% 25%
Time out
0% 0% 14% 40% 47% 58% 38% 2%
Sign out 0% 0% 9% 0% 36% 33% 55% 67%
Led by anaesthetist at hospital 2
Led by surgeon at hospital 2
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Key Points• A hospital which rolled out the checklist
independent of a study protocol exhibited poor compliance– This hospital may be more typical of
mainstream New Zealand– Implementation (or re-implementation)
strategies potentially make a significant difference
• A further drift in engagement at Hospital 1, but Sign Out had improved
• Senior team members leading domains gets better engagement
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Next step – sustain improvements
• Attitude– Analysis and addressing of inappropriate beliefs
• Motivation– Education
• Addressing the more difficult quality issues
• Team behaviours
• Leadership– Involve all 3 professional groups– Change in OR checklist leadership
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Current status – trialling OR team leadership
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Do
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Do
main
items