Use of surgical safety checklists in Australian operating theatres: an observational study

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The use of standardized surgical safety checklists (SSC) has been shown to reduce mortality and morbidity in both developed and developing countries.1 Estimates from systematic reviews suggest a relative risk of death of 0.57 (0.42–0.76 95% CI) and of any complication of 0.63 (0.58–0.67 95% CI)4 when using a SSC compared with not using a SSC, and improved patient outcomes from SSC implementation are considered ‘generally impressive’.5 Similar checklists have now been adapted for use in other areas such as radiology.6 Other reported benefits from SSC use include: increased detection of potential safety hazards, improved communication among operating theatre staff, improved safety attitudes, and efficiency benefits including ensuring all necessary equipment is available before procedures commence.5
A recent study conflicts with the findings of previous systematic reviews and other studies assessing the effectiveness of checklist implementation.9 A large observational study conducted in Ontario, Canada, found no association between checklists and mortality and complications arising from surgery.9 This finding may be because of the complex nature of patient safety interventions, with the exact mechanism, or ‘active ingredient’, of SSCs that leads to safety improvements not being fully understood. It is unlikely that the actual checking of items alone will result in improvements, but this action can engender system and behaviour changes, including a better patient culture and improved teamwork. This may be a result of better team practices such as introductions, briefings and debriefings that are built into the surgical checklist as part of the ‘time out’ component.1 Despite the high self‐reported uptake of checklists in the Ontario study of 98% of hospitals, a possible reason for why no benefit was observed may be that checklists were not actually used in practice.11 Simply mandating the use of checklists may not result in compliance with the checklist or improvements in outcomes without other initiatives such as team training, continuing education and measures to engage staff.9 Opportunities for multidisciplinary engagement, incorporating staff feedback for checklist modification, avoiding redundancies or duplication and provision of staff empowerment have also been highlighted.4
Compliance with SSC use has generally been shown to be good (with an overall compliance of 75%)4 but studies have suggested that some components are ‘often neglected’, or skipped.16 Studies assessing implementation of SSCs at a national level are uncommon, but a survey of Irish hospitals identified gaps in compliance and barriers to implementation.18 In Australia, the use of SSCs has been strongly supported by professional organisations (e.g. the Royal Australasian College of Surgeons), State Governments and the Australian Commission on Safety and Quality in Healthcare. Despite widespread support for the checklists, there is no published research on the implementation or success of the SSC in Australian hospitals. Use of multiple escalating strategies, such as persuasion, support, regulation and sanctions have been used by hospital administrators to implement SSCs in some Australian hospitals.19 The primary aim of this study was to evaluate how safety checklists are used and completed in surgical settings within Australian hospitals.
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