A mixed methods study of challenges in the implementation and use of the surgical safety checklist

Abstract

The surgical safety checklist is an evidence-based global initiative designed to reduce perioperative morbidity and mortality. However, the expounded benefits of the surgical safety checklist have not been realized in naturalistic settings. This may be related to the quality of surgical safety checklists being performed in operating rooms. In this explanatory, sequential, mixed-methods study, 2 trained observers used a standardized tool to record the compliance and quality of the surgical safety checklist completed during 51 surgeries performed at a pediatric academic hospital. We compared compliance with each phase of the surgical safety checklist, the number of checklist items completed, and professionals initiating the surgical safety checklist across surgical specialties and case urgency levels. Interviews with nurses, anesthesiologists, and surgeons (n = 18) were subsequently conducted to explore and contextualize the findings. Hospital-recorded surgical safety checklist compliance (94%, 100%, and 100% on briefing, time out, and debriefing) was higher than the proportion of checklist items completed in matched cases (26%, 59%, and 42%, respectively). Thematic analysis of the interview data suggests this may result from limited staff "buy in," arising from the "top-down" mandated nature of the surgical safety checklist, the perceived lack of benefit in surgical safety checklist completion, and redundancies with other operating room processes. This has led to the surgical safety checklist becoming "an exercise in box ticking" (ie, compliance is recorded without ensuring quality), thereby obfuscating potential safety benefits. These results highlight that compliance data are insufficient for monitoring surgical safety checklist quality. Our study suggests that surgical safety checklist quality may be enhanced through better calibration of the surgical safety checklist with existing procedures and staff expectations through a bottom-up implementation strategy.