Suboptimal compliance with surgical safety checklists in Colorado: A prospective observational study reveals differences between surgical specialties

Abstract

Background: Surgical safety checklists (SSCs) are designed to improve team communication and consistency in care, ultimately avoiding complications. In Colorado, hospitals reported that use of SSCs was standard practice, but a statewide survey indicated that SSC use was inconsistent. The purpose of this project was to directly observe the compliance with the SSC in Colorado hospitals, through direct observation of the perioperative checklist process.

Methods: Ten hospitals participated in a quality improvement initiative. Trained team members recorded compliance with each of the components of the SSC. Data analysis was performed using a chi-squared test or ANOVA, depending on the number of categorical variables, with p < 0.05 determining statistical significance.

Results: Ten hospitals representing statewide diversity submitted 854 observations (median 98, range 24-106). 83% of cases were elective, 13% urgent, and 4% emergent/trauma. There was significant variation across hospitals in: team introductions, cessation of activity, affirming correct procedure, assessing hypothermia risk, need for beta blocker, or VTE prophylaxis. Uniformly poor compliance was observed with respect to assessment of case duration, blood loss, anesthesiologists' concerns, or display of essential imaging. Only 71% of observers reported active participation by physicians; 9% reported that "the majority did not pay attention" and 4% reported that the team was "just going through the motions". There were significant differences among surgical specialty groups in the majority of the elements.

Conclusion: SSCs have been implemented by the vast majority of hospitals in our state; however, compliance with SSC completion in the operating room has wide variation and is generally suboptimal. Although this study was not designed to correlate SSC compliance with outcomes, there are concerns about the risk of a sentinel event or unanticipated complication resulting from poor preparation.

Keywords: Checklist; Compliance; Implementation; Observation; Operating room; Safety; Sentinel events; Surgeons; Surgery.

Figure 1

The Colorado hospital association surgical safety checklist. Based on the World Health Organization checklist, this incorporated Surgical Care Imptrovement Project initiatives.

Figure 2

The surgical safety assessment form. This observation tool was based on the Colorado Hospital Association Surgical Safety Checklist. It was modified to group items according to the perioperative workflow, for ease of completion during the process.

Figure 3

Distribution of case type (n = 854).

Figure 4

Distribution of surgical specialty type (n = 854).

Figure 5

Compliance with pre-anesthesia assessment checklist components prior to induction of anesthesia. * = significant variation across hospitals, p < 0.05.

Figure 6

Compliance with pre-incision time-out checklist components prior to initiation of surgical procedure. * = significant variation across hospitals, p < 0.05.

Figure 7

Compliance with checklist components prior to initiation of surgical procedure, by procedure. * = significant variation across specialty groups, p < 0.05.