Implementation of safety checklists in surgery: a realist synthesis of evidence.

Brigid M. Gillespie; Andrea P. Marshall

Review

Implementation of safety checklists in surgery: a realist synthesis of evidence.

November 4, 2015

Gillespie BM, Marshall AP. Implement Sci. 2015;10:137.

View more articles from the same authors.

Context is an important component of successful checklist implementation initiatives. This review explores the evidence to determine how contextual and implementation factors influence compliance and sustainability of checklist use. The authors found that sustained use of checklists was discipline-specific and was more successful when clinicians were engaged in designing and implementing the checklists.

PubMed citation

Free full text

Related Resources From the Same Author(s)

Clinical handover of the critically ill postoperative patient: an integrative review.

April 15, 2015

Factors that drive team participation in surgical safety checks: a prospective study.

March 23, 2016

Evaluation of a patient safety programme on Surgical Safety Checklist compliance: a prospective longitudinal study.

August 15, 2018

Enhancing communication in surgery through team training interventions: a systematic literature review.

December 22, 2010

Factors that influence the expected length of operation: results of a prospective study.

January 4, 2012

Interruptions and miscommunications in surgery: an observational study.

May 16, 2012

The impact of organisational and individual factors on team communication in surgery: a qualitative study.

December 16, 2009

Why isn't 'time out' being implemented? An exploratory study.

March 31, 2010

Medication management of COVID-19 patients during transition to virtual models of care: a qualitative study.

December 6, 2023

Medication reconciliation at hospital discharge: a qualitative exploration of acute care nurses' perceptions of their roles and responsibilities.

March 23, 2022

The impact of implementation of family-initiated escalation of care for the deteriorating patient in hospital: a systematic review.

June 22, 2016

Barriers and facilitators to implementing a process to enable parent escalation of care for the deteriorating child in hospital.

August 22, 2018

Effect of using a safety checklist on patient complications after surgery: a systematic review and meta-analysis.

August 27, 2014

Comparing the variability of ingredient, strength, and dose form information from electronic prescriptions with RxNorm drug product descriptions.

August 31, 2022

Effects of a brief team training program on surgical teams' nontechnical skills: an interrupted time-series study.

August 11, 2021

Worldwide incidence of surgical site infections in general surgical patients: a systematic review and meta-analysis of 488,594 patients.

December 8, 2021

Getting the whole story: integrating patient complaints and staff reports of unsafe care.

July 28, 2021

Patient safety in home hemodialysis: quality assurance and serious adverse events in the home setting.

June 3, 2015

Assessing teamwork attitudes in healthcare: development of the TeamSTEPPS teamwork attitudes questionnaire.

October 6, 2010

Practice review: medication reconciliation in the ambulatory setting.

January 31, 2024

Evaluation of medication errors at the transition of care from an ICU to non-ICU location.

March 27, 2019

Understanding hazards for adverse drug events among older adults after hospital discharge: insights from frontline care professionals.

July 20, 2022

Making the journey safe: recognising and responding to severe sepsis in accident and emergency.

November 2, 2016

Advancing health equity in patient safety: a reckoning, challenge and opportunity.

January 13, 2021

The Healthcare Complaints Analysis Tool: development and reliability testing of a method for service monitoring and organisational learning.

February 24, 2016

Patient-centered insights: using health care complaints to reveal hot spots and blind spots in quality and safety.

September 26, 2018

Online patient feedback as a safety valve: an automated language analysis of unnoticed and unresolved safety incidents.

September 14, 2022

Identifying and encouraging high-quality healthcare: an analysis of the content and aims of patient letters of compliment.

August 5, 2020

Stakeholders in safety: patient reports on unsafe clinical behaviors distinguish hospital mortality rates.

May 20, 2020

A review of current and emerging approaches to address failure-to-rescue.

October 19, 2011

Effect of short-term pretrial practice on surgical proficiency in simulated environments: a randomized trial of the "preoperative warm-up" effect.

February 18, 2009

Pediatric emergency nurses self-reported medication safety practices.

June 26, 2013

A team training program using human factors to enhance patient safety.

December 19, 2007

Improving medication safety in primary care using electronic health records.

December 8, 2010

Learning environments, reliability enhancing work practices, employee engagement, and safety climate in VA cardiac catheterization laboratories.

April 6, 2022

Patient complaints in healthcare systems: a systematic review and coding taxonomy.

June 18, 2014

It depends who you ask: divergences in staff and external stakeholder narratives about the causes of a healthcare failure.

November 29, 2023

Medication handling: towards a practical, human-centred approach.

April 3, 2019

Comparison of clinical diagnoses and autopsy findings: six-year retrospective study.

October 18, 2017

Prevalence of adverse drug events in ambulatory care: a systematic review.

July 27, 2011

Opioid-Induced Ventilatory Impairment (OIVI): Time for Change in the Monitoring Strategy for Postoperative PCA Patients.

March 19, 2014

Experiences of transgender and gender nonbinary patients in the emergency department and recommendations for health care policy, education, and practice.

July 21, 2021

Walking the plank: an experimental paradigm to investigate safety voice.

July 31, 2019

The teaching of a structured tool improves the clarity and content of interprofessional clinical communication.

April 29, 2009

Systematic review of medication safety assessment methods.

February 16, 2011

Rapid response systems in adult academic medical centers.

September 2, 2009

To what extent do pediatricians accept computer-based dosing suggestions?

January 17, 2007

Development and usability testing of the Agency for Healthcare Research and Quality Common Formats to capture diagnostic safety events.

May 25, 2022

Interventions against bullying of prelicensure students and nursing professionals: an integrative review.

November 21, 2018

Perceived value of ward-based pharmacists from the perspective of physicians and nurses.

April 4, 2012

Integrating principles of safety culture and just culture into nursing homes: lessons from the pandemic.

January 12, 2022

Self-reported medical, medication and laboratory error in eight countries: risk factors for chronically ill adults.

February 9, 2011

Approaches to decreasing medication and other care errors in the ICU.

September 25, 2013

Defining impact of a rapid response team: qualitative study with nurses, physicians and hospital administrators.

March 21, 2012

Prescription and transcription errors in multidose-dispensed medications on discharge from hospital: an observational and interventional study.

January 18, 2012

Hospital doctors' workflow interruptions and activities: an observation study.

March 16, 2011

Pharmacist work stress and learning from quality related events.

November 9, 2016

Patients' perception of types of errors in palliative care—results from a qualitative interview study.

September 7, 2016

Inappropriate medication use in the elderly: results from a quality improvement project in 99 primary care practices.

April 23, 2008

Acting wisely in complex clinical situations: 'Mutual safety' for clinicians as well as patients.

October 13, 2021

How to use an article about quality improvement.

December 1, 2010

Association of pharmaceutical industry marketing of opioid products with mortality from opioid-related overdoses.

February 6, 2019

Patient safety culture in primary care: developing a theoretical framework for practical use.

August 22, 2007

The association between culture, climate and quality of care in primary health care teams.

July 11, 2007

Patient involvement in patient safety: a qualitative study of nursing staff and patient perceptions.

August 13, 2014

Sensemaking and learning during the Covid-19 pandemic: a complex adaptive systems perspective on policy decision-making.

September 16, 2020

Conceptualising learning from resilient performance: a scoping literature review.

January 10, 2024

Speaking up about patient safety in psychiatric hospitals - a cross-sectional survey study among healthcare staff.

November 6, 2019

For 4 days, the hospital thought he had just pneumonia. It was coronavirus.

March 25, 2020

Patient safety and mental health-a growing quality gap in Canada.

October 6, 2021

How safe is my intensive care unit? An overview of error causation and prevention.

November 21, 2007

Crew resource management improved perception of patient safety in the operating room.

January 6, 2010

Assessment of the safety of discharging select patients directly home from the intensive care unit: a multicenter population-based cohort study.

August 29, 2018

Six steps from head to hand: a simulator based transfer oriented psychological training to improve patient safety.

February 7, 2007

Patient identification of diagnostic safety blindspots and participation in "good catches" through shared visit notes.

January 18, 2023

Distractions and surgical proficiency: an educational perspective.

January 20, 2010

What and when to debrief: a scoping review examining interprofessional clinical debriefing.

January 24, 2024

The role of organizational and professional cultures in medication safety: a scoping review of the literature.

January 15, 2020

Diagnostic error in pediatrics: a narrative review.

March 23, 2022

Patient risk factors for medical injury: a case–control study.

January 26, 2011

Factors differentiating nursing homes with strong resident safety climate: a qualitative study of leadership and staff perspectives.

February 15, 2023

Assessment of requests for medication-related follow-up after hospital discharge, and the relation to unplanned hospital revisits, in older patients: a multicentre retrospective chart review.

December 8, 2021

The role of safety culture in influencing provider perceptions of patient safety.

December 14, 2016

Speaking up or remaining silent about patient safety concerns in rehabilitation: a cross-sectional survey to assess staff experiences and perceptions.

July 6, 2022

Surgical safety checklist audits may be misleading! Improving the implementation and adherence of the surgical safety checklist: a quality improvement project.

December 22, 2021

Designing human-centered AI to prevent medication dispensing errors: focus group study with pharmacists.

March 20, 2024

Systematic review of serious games for medical education and surgical skills training.

November 21, 2012

Medication safety in primary care practice: results from a PPRNet quality improvement intervention.

July 11, 2012

The impact of improving teamwork on patient outcomes in surgery: a systematic review.

May 2, 2018

Evaluation of the quality of 'do not use' medication abbreviation audits: a key enabler to successful implementation of audit and feedback.

March 24, 2021

Physician perspectives on addressing anti-Black racism.

February 14, 2024

Exploring stakeholder perceptions around implementation of the Operating Room Black Box for patient safety research: a qualitative study using the theoretical domains framework.

November 13, 2019

Do medication samples jeopardize patient safety?

January 28, 2009

Frequency of failure to inform patients of clinically significant outpatient test results.

June 24, 2009

Novel analysis of clinically relevant diagnostic errors in point-of-care devices.

October 19, 2011

Information technology interventions to improve medication safety in primary care: a systematic review.

July 10, 2013

Measure Dx: implementing pathways to discover and learn from diagnostic errors.

September 28, 2022

What has an Airbus A380 captain got to do with OMFS? Lessons from aviation to improve patient safety.

June 12, 2019

Use of the common gas outlet for supplementary oxygen during Caesarean section.

December 7, 2005

A piece of my mind. Coping with fallibility.

March 6, 2005

Related Resources

Patient safety in the operating room.

September 21, 2023

Effect of the surgical safety checklist on provider and patient outcomes: a systematic review.

April 27, 2022

What are we missing? The quality of intraoperative handover before and after introduction of a checklist.

April 6, 2022

A retrospective audit of postoperative days alive and out of hospital, including before and after implementation of the WHO surgical safety checklist.

February 2, 2022

"Some version, most of the time": the surgical safety checklist, patient safety, and the everyday experience of practice variation.

January 19, 2022

Surgical safety checklist audits may be misleading! Improving the implementation and adherence of the surgical safety checklist: a quality improvement project.

December 22, 2021

Impact of the WHO Surgical Safety Checklist relative to its design and intended use: a systematic review and meta-meta-analysis.

November 24, 2021

Surgical teams' attitudes about surgical safety and the surgical safety checklist at 10 years: a multinational survey.

November 17, 2021

A systematic review of interventions used to enhance implementation of and compliance with the World Health Organization surgical safety checklist in adult surgery.

October 6, 2021

Society for Maternal-Fetal Medicine Special Statement: Surgical safety checklists for cesarean delivery.

September 22, 2021

Are operating room distractions, interruptions, and disruptions associated with performance and patient safety? A systematic review and meta-analysis.

May 19, 2021

Intraoperative sentinel events in the era of surgical safety checklists: results of a national survey.

March 3, 2021

How does the WHO Surgical Safety Checklist fit with existing perioperative risk management strategies? An ethnographic study across surgical specialties.

March 18, 2020

Checking In on the Checklist.

February 5, 2020

Impact of the World Health Organization surgical safety checklist on patient safety.

June 12, 2019

How one health system overcame resistance to a surgical checklist.

May 29, 2019

Reducing surgical mortality in Scotland by use of the WHO Surgical Safety Checklist.

May 8, 2019

Operating room fires.

February 6, 2019

Scaling safety: the South Carolina Surgical Safety Checklist experience.

January 9, 2019

Evaluation of a patient safety programme on Surgical Safety Checklist compliance: a prospective longitudinal study.

August 15, 2018

Enhancing the quality and safety of the perioperative patient.

February 7, 2018

WebM&M Cases

Add-on Case and the Missing Checklist

August 1, 2017

Narrative feedback from OR personnel about the safety of their surgical practice before and after a surgical safety checklist intervention.

July 12, 2017

Mobilising or standing still? A narrative review of Surgical Safety Checklist knowledge as developed in 25 highly cited papers from 2009 to 2016.

June 21, 2017

Introductions during time-outs: do surgical team members know one another's names?

May 24, 2017

Mortality trends after a voluntary checklist-based surgical safety collaborative.

May 3, 2017

Time-out and checklists: a survey of rural and urban operating room personnel.

April 12, 2017

Mobilising a team for the WHO Surgical Safety Checklist: a qualitative video study.

March 1, 2017

Implementation science: a neglected opportunity to accelerate improvements in the safety and quality of surgical care.

December 21, 2016

Using standardized OR checklists and creating extended time-out checklists.

October 5, 2016

See More About The Topic

Operating Room

Health Care Executives and Administrators

Surgery

Surgical Complications

Epidemiology of Errors and Adverse Events

Implementation of safety checklists in surgery: a realist synthesis of evidence.

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

Implementation of safety checklists in surgery: a realist synthesis of evidence.

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

Submit Your Innovations

Continue as a Guest

Continue Logged In

Submit Your Innovations

Continue as a Guest

Continue logged in

New Users to the PSNet site