Assessment of the Implementation of a Surgical Preoperative Checklist

Abstract

Introduction: Peri-operative checklists are mandated by many hospitals based on the reduction in morbidity and mortality seen with utilization of the World Health Organization's (WHO) “Surgical Safety Checklist.” Although an adapted peri-operative checklist was implemented within our hospital system without formal system-wide training, compliance with the checklist is reported to be 100%. We hypothesize that compliance does not measure fidelity of implementation, in that all items on the checklist are not performed as intended. Methods: Over a 10 week period, a prospective study was performed evaluating the completion of the 12 pre-incision components of the surgical checklist. Pediatric surgical operations, occurring in the operating room or in neonatal and pediatric intensive care units, were randomly selected for direct observation. Emergent cases were excluded. the evaluated checkpoints include essential parties present, team members identified, patient name/procedure verified, incision site confirmed, team member concerns addressed, administration of appropriate antibiotics (if applicable), essential imaging displayed (if applicable), anticipated case length stated, anticipated risk of blood loss stated, and sterility indicator confirmed. Essential parties included anesthesiology attending or fellow, pediatric surgical attending or fellow, circulating nurse, and scrub technologist. Results: 142 pediatric surgical cases were observed. Hospital data demonstrated 100% compliance with the pre-incision phase of the checklist for these cases. Our observation revealed that in 3.5% of cases the checklist was not performed at all. None of the cases completely executed all items on the checklist, and the average number of checklist items performed in the observed cases was five. the most commonly performed checkpoints were the confirmation of patient name and procedure (99.3%) and administration of antibiotics (88.1%). the rest of the checkpoints were performed in less than 60% of cases (figure). Conclusions: These data show that despite the 100% documented completion of the pre-incision phase of the checklist, most of the individual checkpoints are not routinely performed. These findings demonstrate lack of fidelity in implementing the checklist, which may be a reflection of the poor strategy in disseminating and implementing this patient safety practice. Failure of the system to measure the appropriate implementation metrics and to fully adopt the evidence-based intervention could lead to failure to achieve the intended outcomes. the impact and etiology of non-compliance with all components of the surgical checklist requires further investigation.