How does the WHO Surgical Safety Checklist fit with existing perioperative risk management strategies? An ethnographic study across surgical specialties

Hilde Valen Wæhle,Siri Wiig,Stig Harthug,Eirik Søfteland,Nick Sevdalis,Arvid Steinar Haugen

doi:10.1186/s12913-020-4965-5

Abstract

BackgroundThe World Health Organization (WHO) Surgical Safety Checklist (SSC) has demonstrated beneficial impacts on a range of patient- and team outcomes, though variation in SSC implementation and staffʼs perception of it remain challenging. Precisely how frontline personnel integrate the SSC with pre-existing perioperative clinical risk management remains underexplored – yet likely an impactful factor on how SSC is being used and its potential to improve clinical safety. This study aimed to explore how members of the multidisciplinary perioperative team integrate the SSC within their risk management strategies.MethodsAn ethnographic case study including observations (40 h) in operating theatres and in-depth interviews of 17 perioperative team members was carried out at two hospitals in 2016. Data were analysed using content analysis.ResultsWe identified three themes reflecting the integration of the SSC in daily surgical practice: 1) Perceived usefullness; implying an intuitive advantage assessment of the SSCʼs practical utility in relation to relevant work; 2) Modification of implementation; reflecting performance variability of SSC on confirmation of items due to precence of team members; barriers of performance; and definition of SSC as performance indicator, and 3) Communication outside of the checklist; including formal- and informal micro-team formations where detailed, specific risk communication unfolded.ConclusionWhen the SSC is not integrated within existing risk management strategies, but perceived as an “add on”, its fidelity is compromised, hence limiting its potential clinical effectiveness. Implementation strategies for the SSC should thus integrate it as a risk-management tool and include it as part of risk-management education and training. This can improve team learning around risk comunication, foster mutual understanding of safety perspectives and enhance SSC implementation.

Highlights

The World Health Organization (WHO) Surgical Safety Checklist (SSC) has demonstrated beneficial impacts on a range of patient- and team outcomes, though variation in SSC implementation and staffs perception of it remain challenging
Reflecting on the purpose of the SSC, we propose that for a safety intervention aiming at human behaviour, it is essential that all team members share an understanding of clinical risk and risk management strategies; and that the intervention is embedded effectively and efficiently into existing safety practices
Existing checking mechanisms and protocols were considered sufficient, as pre-anaesthetic patient risk assessments; e.g. difficult airways, medications, allergies were performed in advance, and safety tests and -checks of the anaesthesia machine, − equipment and -medications, were incorporated in existing routines and reviewed prior to induction of anaesthesia

Summary

Introduction

The World Health Organization (WHO) Surgical Safety Checklist (SSC) has demonstrated beneficial impacts on a range of patient- and team outcomes, though variation in SSC implementation and staffs perception of it remain challenging. The World Health Organizations (WHO) Safe Surgical Checklist (SSC) [1] has been advocated globally, and in some cases mandated as a surgical safety intervention, aiming to improve information exchange within the perioperative team, and to critically review specific safety items [2]. Clinical effectiveness studies have demonstrated beneficial impact of the SSC implementation on a range of patient- and team outcomes, including mortality rates, complication rates, length of in-hospital stay, teamwork, and adherence to safety processes [3,4,5,6,7,8,9,10]. Questions on how lack of SSC compliance might introduce new risks not present before have been raised [23], prompting calls for the reconsideration of policies mandating the SSC as an organisational safety practice [24]

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