853 / Implementation of a safety surgical checklist

BELGIUM
Classification of the PSP
Type of Patient Safety Practice Not Evaluated
 
Clinical Practice (CP)
Related practices from PaSQ database
"Best fit" category of the reported practice
Surgical / Invasive procedures
Communication There is no specified text here
Topic of the reported practice
Clinical guidelines or pathways
Aim and the benefit of the Patient Safety Practice
 
In several recent studies patient outcomes following surgery have been linked to teamwork and safety culture. The use of a Surgical Safety Checklist was associated with a substantial reduction in postoperative complications and deaths1. The introduction of a perioperative checklist has been strongly supported by the Belgian Government. They proposed a checklist that was based on the original checklist as developed by the WHO, but also supported the idea that adjustments could be made to fulfil individual hospital needs.

Reference
1.Haynes, AB, Weiser TG, Berry WR. A Surgical Safety Checklist to Reduce Morbidity and Mortality in a Global Population. N Engl J Med 2009; 360: 491-499.
Description of the Patient Safety Practice
 
Question 3.

The method.

In our hospital a rudimentary version of a Surgical Safety Checklist was introduced in the operation rooms in May 2011 at the opening of our renovated operating complex. In the autumn of 2011 a small working group (general surgeon, head nurse operating room, fomer head nurse operating room and quality control manager) developed a more up to date Checklist, in which the demands of the Belgian Federal Ministery of Health were taken into account. Our most important additions were a section, that had to be filled out at the surgical ward (before the patient was taken to the operation theatre) and one section that was filled out at the recovery (before the patient left for the ward again). In January 2012 this Checklist was implemented.

The implemention.

The implemention was accompanied by a letter of introduction, a handbook regarding the use of the checklist and verbal presentations for the hospital personell. Also the physician (general surgeon) that developed the Checklist attended all operations the first week of the introduction.



The Evaluation.
A.    Evaluation of the use of the Chekclist
In order to assess the correct use of this checklist an analysis was performed in March 2012 (n=483). For this analysis our checklist was divided in eight sections (see figure 1); a count was made of the items per section that were filled out in order to calculate the total number of sections in which all items were correctly registrated. This number was then correlated to the total number of checklists filled out in that period. After this first analysis some adjustments were made to the checklist and this Checklist was introduced in June 2012. A second analysis of the checklist was performed in June 2012 (n=444) and a third in January 2013 (n=464).
The percentage of completeness of filling out the different sections increased for all sections between March and June 2012 (this increase was statistically significant for all sections, p < 0.001). Also the percentage of completeness increased in the period between June 2012 and January 2013, with the exception of the section “Before arrival in the OR” that decreased; none of this increases reached statistically significancy now (fig. 1).


Figure 1. Comparison of the percentage of completeness of the different sections of our checklist in March 2012, June 2012 and January 2013 (*in the section “Before induction of anesthesia” in June 2012 and January 2013 only the patients were taken into account, that were not operated under local anesthesia (resp. n=372 and =412)). The differences in the measurements between March and June 2012 were statistically significant for all sections (p < 0.001).

Also a comparison was made with the published results of a nation wide survey of the Ministery of Health1. In our hospital the Time-Out section scored better than the national average; the scores for the sections Sign-In and Sign-Out however were lower (Figure 2). In the survey of the Ministery of Health only 25 patients were scored on one particular day in the participating hospitals



Figure 2. Comparison between the average percentage of the completeness of the different sections between Waregem (June 2012 and January 2013) and the national average (FOD 4/2011).


B.    Perception of the safety culture and the use of the checklist.
In addition to the pure mathematic evaluation of the use of the checklist also a validated questionnaire was used to evaluate the perception of the safety culture in the operating rooms and the attitude to the use of the checklist. A comparison was made between the nurses and the physicians working in the operating room.

In regard to the perception of the safety culture in the operating room the questionnaire shows in both groups (nurses and physicians) a comparable result (table 1); only the nurses considered the collaboration with the physicians less optimal than the reverse, a phenomenon that has been described in an other studie2.


    Nurses
(n=32)    Physicians
(n=16)    p-value
I would feel safe being treated here as a patient     4,34    4,63    n.s.
Briefing OR personnel before a surgical procedure is important for patient safety    4,84    4,94    n.s.
I am encouraged by my colleagues to report any safety concerns I may have    3,97    3,88    n.s.
In the ORs here, it is difficult to speak up if I perceive a problem with patient care*    2,38    2,25    n.s.
The physicians and nurses here work together as a well-coordinated team    3,81    4,56    0.002
Personnel frequently disregard rules or guidelines that are established for the OR*    2,66    1,94    n.s.
Total    4,40    4,44    n.s.

Table 1. Comparison of the scores between nursing staff and physicians regarding perception of safety (five point Likert scale; anchored by strongly disagree (1) and strongly agree (5);* reversed score question)

In contrast the questionnaire showed a statistically significant difference in the overall perception of the use of the checklist, in favor of the physicians. They found the use of a checklist improved operation room safety and communication (table 2).

    Nurses
(n=32)    Physicians
(n=16)    p-value

The checklist is easy to use    3,44    3,75    n.s.

The checklist improved operating room safety    3,88    4,44    0.026
The checklist took a long time to complete*    3,06    2,81    n.s.

If I were having an operation, I would want the checklist to be used    4,63    4,63    n.s.

Communication was improved through use of the checklist    3,22    4,13    0.002

The checklist helped prevent errors in the operating     4,34    4,69    n.s.

Total    3.76    4.07    0.014

Table 2. Comparison of the scores between nursing staff and physicians regarding the use of the checklist (five point Likert scale; anchored by strongly disagree (1) and strongly agree (5);* reversed score question)





References

2.    Maquoi S, Haelterman M, Van Lerberghe L. Study on the implementation and the use of the Safe Surgery Checklist in the operation room (Publication FOD VVL, 2012).

3.    Carney BT, West P, Neily J, Mills PD, Bagian JP. Differences in Nurse and Surgeon Perceptions of Teamwork: Implications for Use of a Briefing Checklist in the OR. AORN J 2010; 91: 722-729.

Attachment of relevant written information and/or photos, as appropriate
There is no specified text here
There is no specified text here
There is no specified text here
There is no specified text here
Effectiveness of the Patient Safety Practice
 
Degree of implementation of reported practice
Yes, fully
Level of implementation of reported practice
Team level
Specific and measurable outcome for the reported practice were defined
No
A baseline measurement before implementation of the reported practice was obtained
No
A measurement after full implementation of the reported practice was obtained
No
Evaluation of a "positive" effect of the reported practice on Patient Safety
Effect not known or the intervention has not yet been evaluated
Type of before-and after evaluation
There is no specified text here
Enclosure of a reference or attachment in case of published evaluation's results
not yet
There is no specified text here
Health care context where the Patient Safety Practices was implemented
 
Community care facility
Hospital
Transferability
 
Successful implementation of this Patient Safety Practice in other health care settings than above stated
No
Specification of implementation in another health care setting(s)
There is no specified text here
Successful implementation's level  of this Patient Safety Practice across settings
There is no specified text here
Involved health care staff
 
Physicians
Nurses
Quality manager
Patient Involvement
 
Direct service user's involvement as integral part of this Patient Safety Practice
No
Specification of the service users or their representatives' involvement in the implementation of this Patient Safety Practice
There is no specified text here
Point of time in which service user or their reprasentatives' involvement takes place
There is no specified text here
Active seeking of service users' opinion, feedback, experience, etc. as integral part of this Patient Safety Practice
There is no specified text here
Short description of the service users' level of involvement
There is no specified text here
Public accessibility of information regarding this Patient Safety Practice to patients and citizens/service users
No
List of sources where public information is accessible
There is no specified text here
Implementation of the Patient Safety Practice
 
Existing collaboration with other countries or international organisations related to implementation of this Patient Safety Practice
No
Problems encountering in the implememntation course of this Patient Safety Practice like lack of motivation, no management support, etc.
No
List of the most prevelent difficulties encuntered during implementation of this Patient Safety Practice
There is no specified text here
List of the most prevalent drivers for a successful implemetation of this Patient Safety Practice
Sharing of progress information among involved staff
Use of any specific incentives to enhance motivation while implementing this Patient Safety Practice
No
Description of used incentives, if any.
There is no specified text here
Existence of support or approval by the clinical or hospital management or any other hihg level authority in the implementation process of this Patient Safety Practice
Yes
Costs of the Patient Safety Practices
 
Completion of cost calculation related to this Patient Safety Practice
No
Total number of person days required to implement this Patient Safety Practice
Clinical staff: There is no specified text here
External consultants: There is no specified text here
Support staff: There is no specified text here
Managerial staff: There is no specified text here
Others: There is no specified text here
Not relevant: There is no specified text here
Total number of person days required for training as preparation for implementation of this Patient Safety Practice
Clinical staff: There is no specified text here
External consultants: There is no specified text here
Support staff: There is no specified text here
Managerial staff: There is no specified text here
Others: There is no specified text here
Not relevant: There is no specified text here
Total cost in Euro of specific equipment (machines, software, communications supplies, etc.) needed to support implementation of this Patient Safety Practice
There is no specified text here
Associated cost with a work reduction or foregoing in order to deliver this Patient Safety Practice
There is no specified text here
Contact information
 
Name: Dominique Verheyen
Country: BELGIUM
Organisation: OLV v Lourdes Hosiptal Waregem
E-mail: dominique.verheyen@ziekenhuiswaregem.be
Phone: 003256623111
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