#60
PROJECT NAME: Continued Challenges but Promising Insights
into Surgical Safety Checklist Implementation
Institution: UT Houston
Primary Author: Luke Putnam, MD
Secondary Author: Shauna Levy, MD
Project Category: Education
Background:
The three-phase Surgical Safety Checklist (SSC) is a peri-operative safety tool designed by the
World Health Organization that has led to worldwide reductions in patient morbidity and
mortality. Initial implementation of our customized SSC at the hospital system level was done
poorly, which led to poor checklist adherence (execution of the individual checkpoints as
designed). The pediatric operating room Safety Council designed a multi-dimensional
intervention that included pediatric operating room specific checklist revisions and
reimplementation of the SSC after encouraging stakeholder buy-in. A subsequent review one
year ago demonstrated significant improvements in checklist adherence. We hypothesize that
our ongoing educational and team-building efforts have produced sustainable improvements in
checklist adherence.
Methods:
After IRB approval, direct observation by trained assessors of the pre-incision phase of the
checklist was used to assess checklist adherence during three different observational periods
(Table 1). During each data collection period, trained assessors observed a convenience
sample of pediatric surgical cases for adherence with 14 pre-incision phase checkpoints.
Fifteen specialties were observed in six different operating rooms. Operative case selection was
random. Regression analysis was used to determine statistical significance.
Results:
Since the initial observational period in 2011, a total of 873 pediatric surgeries were observed by
trained individuals. Of these, 144 cases were observed prior to the initial SCC educational
interventions, 373 one year post-interventions, and 356 cases two years after SSC initiation.
Checkpoint adherence was observed as 30%, 78%, and 96%, respectively (p<0.05).
Completion of all checkpoints was achieved in 0%, 19%, and 61% of cases, respectively. The
overall pre-incision median (interquartile range) number of checkpoints completed during each
time period improved from 4 to 11 to 14 (13-14, p<0.05).
Conclusions:
Ongoing SSC implementation strategies significantly and sustainably improved checkpoint
adherence. We are encouraged that checklist adherence has improved since our last
observation and is nearing perfection, but continued accountability and investigation of factors
that may be impeding 100% adherence is warranted. Outcomes data is currently unknown at
this time.
Table 1
2009
Checklist
initiated at
system
level
Observation 1
(July-Aug
2011)
Intervention 1
(Aug 2011- July
2012)
Observation 2
(July-August
2012)
Intervention 2
(August 2012July 2013)
Observation 3
(July-August
2013)
Direct
observation of
the checklist
- Safety Council
- Safety lectures
- Revised SSC
Direct
observation of
the checklist
- Audit/feedback
- Continued
safety lectures
- Safety Council
Direct
observation of
the checklist