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Patient Safety Tip of the Week
January 30, 2024
Is Your Surgical
Safety Checklist Working?
Our February 2024 What's New in the Patient Safety World Both
Sides of the Black Box discusses some surprising resistance to adoption of
video recording in the OR. Our March 17, 2020 Patient Safety Tip of the Week Video Recording in the OR
highlights the many potential uses of such video recording to improve patient
safety. Perhaps the greatest impact of video recording in the OR is to evaluate
how well the surgical timeouts are being handled. Virtually all hospitals perform
surgical timeouts, usually with the WHO Surgical Safety Checklist or
equivalent. But there is a big difference between having a formal timeout
protocol and checklist and actually using it in the intended fashion. We often
see these performed in a perfunctory manner.
The first 3 columns
listed below recommended use of video recording as one means of improving
compliance with surgical timeouts or elements of a safe surgery checklist. In
fact, Overdyk et al. (Overdyk 2016) demonstrated that real-time feedback from
video recording conferred a 3.37-fold increased odds of time-out compliance
versus no feedback, and 2.75-fold and 2.4-fold increased odds of compliance
with the sign-in and sign-out components of the WHO surgical safety checklist,
respectively. It also led to some improvements in efficiency (shorter OR
turnaround times for scheduled cases).
Several recent
articles discuss the fidelity of surgical safety checklist implementation. Moyal-Smith
et al. (Moyal-Smith
2023) created CheckPOINT, (Checklist Performance Observation for Improvement), a simple tool to assess Surgical
Safety Checklist implementation
fidelity, and to test its reliability using video simulations, and usability in
clinical practice. They note barriers to implementing the Surgical
Safety Checklist, including team
culture, resistance from surgical team members, clinical workflows, and
checklist design. The CheckPOINT tool evaluates not only adherence to the Surgical
Safety Checklist (which could mean simply checking the boxes) but also the quality
of checklist delivery, and participant responsiveness, which is the degree of user
engagement and enthusiasm for the checklist. The four main items in CheckPOINT are:
·
Checklist
Adherence
·
Communication
Effectiveness
·
Attitude
·
Engagement
Each item is rated
on a 7-point scale and includes specific questions used to come to those ratings.
In field testing, CheckPOINT
proved easy to use and had good inter-rater reliability.It requires minimal training
and can be used to evaluate how surgical teams use the Surgical Safety
Checklist. The authors conclude that the CheckPOINT tool offers organizations a low-resource tool that can be used
to identify areas on which to focus efforts to improve communication, teamwork
and, ultimately, patient safety.
An accompanying
editorial, Gillespie and Ziemba (Gillespie
2024) stress the need for observational tools like CheckPOINT offer a more comprehensive assessment of the fidelity of Surgical Safety Checklist.use, team communication,
and team performance. They note that tools
such as the CheckPOINT are ideally suited for gathering information following
the first introduction of an surgical safety checklist or following changes to
an established process. That can help staff identify areas where the fidelity
of implementation may not be as successful or robust, allowing focus on strategies
for improvement.
Etheridge et al. (Etheridge
2024) lamented that not all implementation
efforts have produced positive results, pointing to a mandate-driven initiative
in Ontario,Canada. They note the crucial point is that meaningful improvements
in surgical safety require effective implementation of the Surgical
Safety Checklist.
So, they developed a reimplementation package and
undertook reimplementation of the Surgical
Safety Checklist at two large academic medical centers in Singapore. Implementation
outcomes included both penetration and fidelity. The primary effectiveness
outcome was team performance, as assessed by trained observers using the Oxford
Non-Technical Skills (NOTECH) system before and after reimplementation.
They used the Exploration, Preparation, Implementation, Sustainment
framework and best practices from implementation science and human factors engineering
were combined to redesign the checklist.
Penetration of the checklist was excellent both before and
after the reimplementation, but there were significant improvements in all measures
of fidelity after reimplementation. Significant improvements were noted in 9 of
12 composite areas on culture of safety surveys. Moreover, preliminary results
on run charts suggested reductions in patient safety events, mortality, and
serious complications.
The authors conclude that this is the strongest and most direct
evidence to date that effective Surgical Safety Checklist use requires careful
attention to the principles of implementation science.
How do you evaluate the fidelity of your Surgical Safety
Checklist or equivalent performance? Use of some of the tools in these articles
may help you get a better feel for true effectiveness rather than just
checking all the boxes. And, If at first you dont succeed
., maybe its
time to undertake a reimplementation.
Some of our previous columns discussing video recording:
September 23, 2008 Checklists
and Wrong Site Surgery
December 6, 2010 More
Tips to Prevent Wrong-Site Surgery
November 2011 Restricted
Housestaff Work Hours and Patient Handoffs
March 2012 Smile...Youre
on Candid Camera!
August 27, 2013 Lessons
on Wrong-Site Surgery
March 17, 2015 Distractions
in the OR
November 24, 2015 Door
Opening and Foot Traffic in the OR
March 2019 Another
Use for Video Recording
March 17, 2020 Video Recording in the OR
June 2023 WSJ
on Video Recording in the OR
February 2024 Both
Sides of the Black Box
Some of our prior columns related to wrong-site surgery:
September 23, 2008 Checklists
and Wrong Site Surgery
June 5, 2007 Patient
Safety in Ambulatory Surgery
July 2007 Pennsylvania
PSA: Preventing Wrong-Site Surgery
March 11, 2008 Lessons
from Ophthalmology
July 1, 2008 WHOs
New Surgical Safety Checklist
January 20, 2009 The
WHO Surgical Safety Checklist Delivers the Outcomes
September 14, 2010 Wrong-Site
Craniotomy: Lessons Learned
November 25, 2008 Wrong-Site
Neurosurgery
January 19, 2010 Timeouts
and Safe Surgery
June 8, 2010 Surgical
Safety Checklist for Cataract Surgery
December 6, 2010 More
Tips to Prevent Wrong-Site Surgery
June 6, 2011 Timeouts
Outside the OR
August 2011 New Wrong-Site Surgery Resources
December 2011 Novel Technique to Prevent Wrong Level Spine
Surgery
October 30, 2012 Surgical Scheduling Errors
January 2013 How Frequent are Surgical Never Events?
January 1, 2013 Dont Throw Away Those View Boxes Yet
August 27, 2013 Lessons on Wrong-Site Surgery
September 10, 2013 Informed Consent and Wrong-Site Surgery
July 2014 Wrong-Sided Thoracenteses
March 15, 2016 Dental
Patient Safety
May 17, 2016 Patient
Safety Issues in Cataract Surgery
July 19, 2016 Infants
and Wrong Site Surgery
September 13, 2016 Vanderbilts
Electronic Procedural Timeout
May 2017 Another
Success for the Safe Surgery Checklist
May 2, 2017 Anatomy
of a Wrong Procedure
June 2017 Another
Way to Verify Checklist Compliance
March 26, 2019 Patient
Misidentification
May 14, 2019 Wrong-Site Surgery and
Difficult-to-Mark Sites
May 2020 Poor
Timeout Compliance: Ring a Bell?
September 14, 2021 Wrong Eye Injections
October 5, 2021 Wrong Side Again
November 9, 2021 Ensuring Safe Site Surgery
February 15, 2022 Wrong-Side Chest Tubes
May 2022 PPSA:
Updated Wrong-Site Surgery Recommendations
June 13, 2023 Preventing Wrong-Site
Surgery
November 2023 Importance
of Timeouts Outside the OR
References:
Overdyk FJ, Dowling
O, Newman S, et al. Remote video auditing with real-time feedback in an
academic surgical suite improves safety and efficiency metrics: a cluster
randomized study. BMJ Qual Saf 2016; 25: 947-953
https://qualitysafety.bmj.com/content/25/12/947
Moyal-Smith R, Etheridge JC, Turley N, et al. Checkpoint: a simple
tool to measure surgical safety checklist implementation fidelity. BMJ Quality
& Safety 2023; Published Online First: 21 September 2023
https://qualitysafety.bmj.com/content/early/2023/09/20/bmjqs-2023-016030
Gillespie BM, Ziemba JB. Lost in translation: does measuring
adherence to the Surgical Safety Checklist indicate true implementation
fidelity? BMJ Quality & Safety 2024; Published Online First: 08 January
2024
https://qualitysafety.bmj.com/content/early/2024/01/08/bmjqs-2023-016617
Etheridge JC, Moyal-Smith R, Yong TT, et al. Transforming
Team Performance Through Reimplementation of the Surgical Safety Checklist.
JAMA Surg 2024; 159(1): 78-86
https://jamanetwork.com/journals/jamasurgery/article-abstract/2811921
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