Checklists are great
tools for helping ensure that important steps in a variety of patient safety
activities are not missed. But checklists are only as good as the degree to
which they are complied with, as exemplified in our May 2, 2017 Patient Safety
Tip of the Week Anatomy
of a Wrong Procedure.
Weve often noted
that most facilities have no idea whether their Universal Protocol or Surgical
Safety Checklist is being used well. That is because they dont audit
compliance with its use. Even those that think they have good compliance
usually rely on self-reporting rather than more objective measurements. We
recommend direct observation or use of video recording as ways to assess
compliance. The former is obviously subject to the Hawthorne effect. The latter
is more effective but many physicians and OR personnel have objected to video
recording and few ORs use it today.
A third way is to use simple audio recording. While audio recording may miss some of the body language aspects that may provide important details about communication in the OR, it may still provide insight into how well OR teams are complying with the checklists. A recent study reported use of such an audio audit of use of a Surgical Safety Checklist at a US hospital (Salgado 2016). Whereas a compliance rate was previously reported as 97.6%, the audio-recorded audits revealed a precisely executed checklist only 73.6% of the time.
The Salgado article is useful not only for details about the method of recording but also for the checklist scoring system they developed.
Note that their version of the WHO Surgical Safety Checklist was modified for their own use, as is strongly recommended for any facility using the checklist. So some items on their checklist audit tool may differ from those you might audit at your facility. They audited items from all 3 components of the Surgical Safety Checklist (pre-procedure, just before skin incision or start of procedure, and post-procedure before patient leaves the OR).
Audit of the middle
section of the checklist (just before skin incision or start of the procedure)
revealed suboptimal compliance with two key items we have stressed before.
Confirmation of the procedure with the consent form was only completed in 69%
of audited cases. And asking whether essential imaging was required was
completed in only 81% of audited cases. We found it somewhat surprising that
the question about whether antibiotic prophylaxis has been given within the
last 60 minutes was only completed in 80% of audited cases. On the other hand,
we were pleased to see that this facility included a question about letting the
alcohol prep dry before draping and that compliance with this item was 89%. We
were also glad to see the item addressing anticipated surgical specimens and
tests was completed in 94% of cases. The item asking whether venous
thromboembolism prophylaxis is needed is also a question we think is important
(though we usually recommend it as an item to be discussed during the pre-op
huddle) but this item was only completed in 55% of audited cases.
Regarding the
pre-procedure portion of the checklist, compliance was pretty good regarding
the anesthesia check, medication check, and pulse oximetry items. Risk of
hypothermia was formally completed in only 52%. The site marked item was
complete in only 56%. That sounds awfully low, but it is not clear whether this
is adjusted for those cases in which site marking is not indicated (eg. bilateral procedures).
Compliance with the
post-procedure portion of the checklist was, in general, poor. Several items
are of particular concern. One is that labeling of specimens was completed as
an item in only 34% (it is not clear from the article whether this might
reflect that specimens were not taken in some cases). And only 43% of cases
completed the item asking if instrument, sponge and needle counts were
complete. And only 22% asked whether any equipment problems needed to be
addressed.
They were also able
to identify some barriers to communication, such as distractions. Those
identified included personal conversations, staff changes, and room setup noise
as major distractors. The researchers also looked at whether quiet was
requested for various parts of the checklist and whether quiet was actually
achieved. Quiet was actually achieved in less than 50% for each section of
the checklist and for only 20% for the post-procedure period.
Note that the
Surgical Safety Checklist used by Salgado et al. asked for confirmation of the
procedure with the informed consent. It did not require confirmation with the
H&P. We feel that requiring the latter is equally important since informed
consents are not without problem (see our September 10, 2013 Patient Safety Tip
of the Week Informed
Consent and Wrong-Site Surgery). And, as discussed in our May 2, 2017
Patient Safety Tip of the Week Anatomy
of a Wrong Procedure, it is
critical that all participants have actually looked at these primary source
documents (the consent and the H&P).
You should refer to
the actual article for a description of the audio recording protocol.
The Salgado study is
an excellent contribution to patient safety. Every facility should be auditing
compliance with their checklists and both the audio format and the scoring tool
developed by these researchers could be adapted to almost any facility. We also
suspect that the results found in their audit are probably pretty
representative of what the majority of facilities will find when they do their
own audit.
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
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
Some of our prior columns on checklists:
References:
Salgado D, Barber KR, Danic M. Objective Assessment of Checklist Fidelity Using Digital Audio Recording and a Standardized Scoring System Audit. Journal of Patient Safety 2016; Published Ahead of Print Post Author Corrections: November 2, 2016
Print PDF
version
http://www.patientsafetysolutions.com/