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Practical current issues of carrying out and implementing pre-operative Surgical checklists

Introduction Keble, 2002 argued that although surgery is standard practice in medical treatment,

there is a high rate of major consequences and complications, which is projected at 3-

17%. Treadwell et al., (2013) stated that numerous complications are, in fact, avoidable,

and surgical checklists are intended to prevent any potential errors that may arise during

surgery or pre-operatively. The Surgical Patient Safety System (SURPASS), was

agreed to be an ideal example of the surgical checklist, which covers all the surgical

care amongst patients’ admitted to, discharge from hospitals (de Vies et al., 2010).

Furthermore, The

World Health Organisation’s (WHO) SSC checklist was adopted and implemented

throughout the majority of the National Health Service (NHS) hospitals in the United

Kingdom. This study is intended to discuss and explore the current matters with

adopting surgical checklists, the human factors of teamwork and the effects of efficacy.

Methodology

A widely search has been employed using a brief systematic literature review in order to

accomplish this study’s aim to find as much as possible of the studies that relevant to

the topic under research, to identify, choose and synthesise all the studies published

related to this topic. In addition, employing a systematic review, which requires an

explicit method to distinguish that, can reliably be stated on the basis of these studies.

(Green and Thurgood et al, (2013). In order to evaluate the significant literature to carry

out the review a comprehensive literature search was showed using multiple data

sources and scoping (Malterud et al, 2001). As the issues of implementing pre-operative

surgical checklists are still current and topical throughout perioperative practice (Watters

et al., 2014).

The following subject and keyword search terms were used in order to obtain

comprehensive information on implementation issues and the WHO checklist: patient

safety, surgical safety, checklist, WHO checklist, and teamwork.

The aforementioned terms were chosen in connection with implementing pre-operative

surgical checklists in the operating room (OR) and therefore has a great interest in

ensuring patient safety and minimising complications by preventing OR team members

from missing important details during surgery. The author carried out a literature scan by

employing. Google Scholar is also potentially useful for scoping, and the electronic

medical database PubMed. Furthermore, the searches were filtered by implementing

the inclusion and exclusion criteria (Meline, 2006). Despite the studies and articles

describing the usage of the WHO checklist and SURPASS checklist, only studies and

articles focusing on the WHO SSC were included. Although other checklists are

recognised and adopted, they have not been implemented on a large-scale, therefore,

the study did not focus on them. other inclusion criterium for this study is that highlight

on any published articles between 2008 and 2018 in the UK in keeping with the WHO

SSC, which was first launched in the year 2008 (WHO, 2009), and by February 2010 it

had been adopted and implemented throughout the National Health Service (NHS)

hospitals within the United Kingdom with the intention of ensuring the safety of each

patient undertaking surgery.

The study included only studies carried out in the English language and implementation

of the SSC. The study includes all articles that are concentrating on the human

perspective and written in the as it is a global language

Discussion The WHO Surgical Safety Checklist Walker et al, (2012) asserted that The WHO checklist was developed after extensive

research, with the aim to decrease errors and accidents in the OR while increasing

teamwork and communication (The checklist covers 19 items in three phases: before

the induction of anaesthesia, before the incision of the skin, and before the patient exits

the operating room and the team members are required to sign the checklist in order to

complete it (WHO, 2018).

Previous studies found that checklists properly minimise medical errors before, during

and after surgery (Arriaga, 2013; Neily, 2009). Similarly, Arriaga et al. (2013) argue that

checklists dramatically improve adherence to critical procedures of care in surgical

crises.

Furthermore, Neily (2009) and Neily et al. (2010) suggested that incorporating checklists

and communication strategies are associated with a reduction in surgical mortality.

Consequently, Treadwell et al. (2013) reported that there are several advantages of

using a Checklist include encourage teamwork, enhance communication, catch near-

misses and anticipate any potential complications

Some studies show that within the WHO SSC, developments and enhancements have

been established in urgent surgery (Weiser et al., 2010) and safety attitudes (Haynes et

al., 2011). According to Helmio et al. (2012) healthcare staff does support the use of the

SSC, also reported that 76% of OR staff agreed the checklist improved safety, and 68%

agreed to it improved error prevention. In addition to improving patient safety by using

the SSC is designed to improve safety during surgical procedures regarding

performance and teamwork and communication in the OR.

An evaluation carried out by the NHS suggests that along with improving patient safety,

the SSC strived to achieve other benefits including financial profits and organizational

improvements (National Patient Safety Agency, 2011). There are several ways for the

surgical improvements to take place within a hospital these include reduction in health

care costs so that new equipment can be afforded (Litigation Authority, 2010). In order

to avoid making the checklist overly complicated, the WHO issued a manual to be

aligned with the introduction of the SSC and in the UK. The modification included an

additional brief that would be read by the surgeon and their team before starting the

surgical operation (Walker et al., 2012). Other versions of this checklist have also been

published for different surgical procedures and operations, such as endoscopy and

bowel surgery, so the SSC is personalized to the needs of the specialty so that

everything is clear (NPSA WHO Surgical Safety Checklist, 2009). However, despite the

advantages of patient safety, there are many potential obstacles to the implementation

of the SSC (Pugel et al., 2015).

Barriers to the use of the checklist

The perioperative mortality rate (POMR) is projected at around 0.4-0.8%, and the rate of

major difficulties is an indicator of the quality and safety of the operation/surgery.

Therefore, the issues and obstacles obstructing the implementation of the WHO SSC

are practicable throughout perioperative practice as patient safety is one of the biggest

public health concerns (Gawande, 1999; Watters et al., 2014).

The present review found that there are a significant variability and a lack of rigor in the

performance of the WHO SSC, which could compromise and improve the patient’s

safety and the ability of the OR members to work as a team to give the patients the right

treatment. Additional constraints to the rigor of carrying out the checklist include poor

teamwork and human factors, the timing of when the checklist should be carried out and

issues with the implementation (O’Connor et al., 2013). Out of the contributory factors,

one of the most common is wrong-site surgeries caused by lack of teamwork and a

lapse of communication in the OR (Neily, 2009).

Communication lapses Leonard et al. (2004) have suggested that the leading causes of patient damage are

communication failures. Leonard et al. (2004) reported that every operation has a series

of steps that are required to be practised appropriately before and after the operation.,

for instance, the accurate equipment necessitate use by the surgeons to carry out the

operation, all necessary equipment must be available, and the working condition of this

equipment must be checked and ensured before operating commences. In addition, the

necessary drugs need to be administered accordingly, and the anaesthetist is required

to administer the anaesthetic at a certain time before commencing surgery. Thus, there

is the potential of medical errors and failures in communication lead to misconception

probably happen at any time amongst the OR team members during the relevant steps

before the operation.

Hu et al., (2012) reported in their study that communication lapses might occur every

seven to eight minutes and affect roughly 30% of OR interactions. The operating room

teamwork interdependently of each other and thus, it is essential that the staff of the OR

includes the nurses, anaesthetists and surgeons - communicate effectively in order to

reduce the risk of medical errors such as wrong-site surgery and the administration of

the wrong medication, and to ensure the safety of the patient before, during and after

surgical operation. According to Henrickson et al. (2009), it is conceivable to minimise

more than half the communication failures by notifying each member of OP staff to

potential complications and encouraging the staff to speak out if they notice a potential

medical error occurring through the exam and use of a checklist.

Teamwork A large body of literature has emphasized the importance of teamwork in the OR to

reduce the medical error (Baker et al. 2007; Manser, 2009). Accordingly, Schaefet et al.

(1994) reported that between 70% and 80% of healthcare errors are caused by human

factors related to poor teamwork and communication between OR team members.

Likewise, s study by O’Connor et al., (2013), established that the checklist is usually

completed prior to surgical operations during a period of high workload, which poses as

a problem for anaesthetists, which in turns impact negatively on their performances.

However, Davenport et al. (2007) alleged that lower rates of risk-adjusted morbidity in

the OR are associated with higher levels of communication between team members.

Additionally, a study on medical errors in the OR, Wiegmann (2007) concluded that poor

teamwork leads to errors and good teamwork leads to detection and correction of errors.

Furthermore, further evidence supports a link between increased teamwork and fewer

errors during surgery (Catchpole, 2008). Likewise, several studies supporting the

developments in patient safety due to teamwork, evaluative studies have also been

conducted on how the OR team use the SSC in daily practice , for instance, an

examination on checklist efficacy was conducted by Levy et al. (2012), results revealed

that administrative records confirmed 100% performance, which was remarkable

finding. However, auditing conducted in the OR revealed less than 50% completion, and

in some cases, only 10% of the checklist was completed, which more likely due to the

disregarded of OR staff to complain with the regulations and they might be considered

as the complicated routine.

Recommendations for improving compliance of the checklist The WHO SSC is effective tool in reducing the complications and consequences due to

disregarding to use the checklist which might minimised the patient safety. However, the

barriers that impeded the application the checklist were discussed in an aforementioned

section clearly hinder its efficacy and ability to ensure patient safety and reduce

complications. O’Connor et al., (2013) suggests that all theatre team members

necessitate being involved in the checklist process. Furthermore, customisation of the

checklist may increase compliance and eliminate the barriers this study found, by

customising the checklist to fit the needs of the OR team , all the recommendations and

the suggestion obtained in this study aligned with the suggestion proposed by previous

study conducted by Russ et al., (2015).

Conclusion It is arguable that the SSC is a very effective system for minimising many potentially life

threating accidents in surgical operations, which caused by human error or disregarded

applied a rigorous application of the checklist.

Another consideration is that failure communication leads to misconception amongst

medical staff in operation theatres, which are relatively common in complex surgical

environments, which can be attributed to many accidents and serious consequences. In

order to improve the consistency of which the SSC is completed, there is a current

essential to address the contribution of medical staff who work in the theatre team in the

process of implementing the checklist. The limitation of dirt the implementation checklist

in UK hospitals probably is the socio-cultural barriers such as the workload of the OR

staff and restrict time frame which probably impacted the medical staff to check and sing

the checklist that should be completed, and on-going training people to enter the OR to

carry out their task.

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Appendix 1

Appendix 2