THE SURGICAL SAFETY CHECKLIST
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THE SURGICAL SAFETY CHECKLIST Dr Jacqueline Hannam Associate Professor Simon Mitchell. Department of Anaesthesiology University of Auckland. Complications after inpatient operations occur in up to 25% of patients Reported crude mortality rate after major surgery is 0.5–5%

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THE SURGICAL SAFETY CHECKLIST Dr Jacqueline Hannam Associate Professor Simon Mitchell

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The surgical safety checklist dr jacqueline hannam associate professor simon mitchell

THE SURGICAL SAFETY CHECKLIST

Dr Jacqueline Hannam

Associate Professor Simon Mitchell

Department of Anaesthesiology

University of Auckland


The surgical safety checklist dr jacqueline hannam associate professor simon mitchell

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%


The checklist at auckland

The checklist at Auckland

Benjamin A BMJ 2008;336:1241-1245


The surgical safety checklist dr jacqueline hannam associate professor simon mitchell

What to audit? 1. Is it used?

Van Klei et al


The surgical safety checklist dr jacqueline hannam associate professor simon mitchell

What to audit? 2. Is it used correctly?

Increased odds of complication or death if information sharing was omitted or poor either intra-operatively or at patient handover.


The surgical safety checklist dr jacqueline hannam associate professor simon mitchell

Definitions

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.”


The surgical safety checklist dr jacqueline hannam associate professor simon mitchell

Method of measurement?

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


The surgical safety checklist dr jacqueline hannam associate professor simon mitchell

Accuracy of retrospective note review

Checking the checkers: an audit of self-reporting checklist use

  • 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)


The surgical safety checklist dr jacqueline hannam associate professor simon mitchell

Checking the checkers - results

  • 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!


The surgical safety checklist dr jacqueline hannam associate professor simon mitchell

Checking the checkers - results

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.


The surgical safety checklist dr jacqueline hannam associate professor simon mitchell

Audit 1:

Direct observation

100 cases at ACH

Primary outcomes

Secondary outcomes

Compliance with

administration of

checklist domains

and domain items

Team

Engagement

2 months, 2010 – 2011 (2 years post checklist roll out)


The surgical safety checklist dr jacqueline hannam associate professor simon mitchell

Domain compliance

Sign In: 99%

Time out: 94 %

Sign Out:2 %

Item compliance

Mean (range)

Sign In: 56% (27 – 100)

Time out: 69% (33 – 100)

Sign Out:NA


Team engagement

Team engagement


Key findings of audit

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


Interventions

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


The surgical safety checklist dr jacqueline hannam associate professor simon mitchell

Simultaneous audit of 100 cases at a study

and a non-study hospital, 2011

Primary outcomes

Secondary outcomes

Team

Engagement

Compliance with

administration of

checklist domains

and domain items


Compliance with domain administration

Compliance with domain administration


Compliance with checklist item administration

Compliance with checklist item administration


Team engagement1

Team engagement

Led by anaesthetist at hospital 2

Led by surgeon at hospital 2


Key points

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


Next step sustain improvements

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


The surgical safety checklist dr jacqueline hannam associate professor simon mitchell

Current status – trialling OR team leadership


The surgical safety checklist dr jacqueline hannam associate professor simon mitchell

Domains

Domain items


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