Implementation challenges can hinder the effectiveness of the WHO Surgical Safety Checklist (SSC). This study describes the validation of the Checklist Performance Observation for Improvement (CheckPOINT) tool to assess SSC implementation fidelity. Based on testing in simulated and real-life clinical practice, researchers found that that the tool can reliably assess implementation fidelity and identify opportunities for improvement.

Disruptive behavior includes behaviors that show disrespect for others and impede safe delivery of patient care. This commentary presents a framework for new physician managers to address disruptive behavior modeled after clinical medicine: diagnose, treat, prevent. The authors stress maintaining curiosity during the “diagnostic” phase, careful consideration of “treatment” and follow-up, and “prevention” of future disruption though intentional training and building a culture of safety.

Labor and delivery is a high-risk care environment. This study evaluated a quality improvement initiative (TeamBirth) designed to promote shared decision-making and safety culture in labor and delivery. This mixed-methods study included both clinicians and patients at four hospitals and found that the program was feasible, increased the use of huddles, and had no negative effects on patient safety.

As part of a quality improvement initiative to enhance surgical onboarding, the authors used semi-structured interviews with 20 physicians to understand potential areas of risk when a physician begins working in an unfamiliar setting. Qualitative analysis found that three key findings: (1) physicians often receive little to no onboarding when starting to practice in a new setting, which can limit their ability to provide safe care; (2) physicians felt onboarding inadequately fostered strong interpersonal relationships among health care teams, which impedes psychological safety and team cohesion, and; (3) physicians noted an increased risk of patient harm during emergency situations in new settings due to lack of understanding of culture, workflow, roles/responsibilities and available equipment.

Ambulatory surgery centers are increasingly utilized to provide surgical care to patients. Quality improvement approaches utilized in the inpatient setting may need to be modified or adapted to be applicable in the ambulatory surgery environment. Researchers describe efforts to implement a surgical safety checklist and infection control techniques across 665 ambulatory surgery centers recruited for the study. They identified several barriers and conclude that the unique aspects of ambulatory surgery centers must be taken into account when implementing quality improvement initiatives.

This study in the Health Affairs patient safety theme issue examines the implementation of surgical safety checklists. Checklists have been shown to improve patient outcomes in randomized control trials, but implementation studies have not consistently demonstrated similar improvements. In this statewide initiative, implementation of the checklist varied significantly among sites. Factors associated with more successful implementation included greater leadership participation, frontline engagement, and more frequent activities for all involved groups, including surgeons, nurses, technicians, and administrators. Sites that invested more funding and time also saw greater checklist implementation. The authors conclude that hospitals that participated more did better. Past PSNet interviews with Lucian Leape and David Urbach discussed their perspectives on surgical safety checklists.

Checklists have been shown to improve surgical outcomes in clinical trials, but their effectiveness in real-world settings is variable. This implementation study examined factors related to checklist use in the operating room for crises rather than routine practice. Investigators surveyed individuals who downloaded a checklist from two websites about whether they used a checklist regularly in specific clinical situations. Thorough checklist implementation, leadership support, and dedicated staff training time led to more regular use of the checklist. Conversely, frontline resistance and lack of clinical champions undermined checklist use. The authors conclude that optimizing organizational conditions should increase the use of checklists during crises in operating rooms. Past PSNet interviews with Lucian Leape and David Urbach discussed their perspectives on surgical safety checklists.

Physicians who receive more patient complaints about communication and behavior are more likely to face malpractice claims. This study examined whether results from surgeons' 360-degree reviews, in which team members evaluate a range of professional attributes and behaviors, were associated with risk of malpractice claims. Surgeons with worse performance for attentiveness, informing others, and considering others' suggestions had a significantly higher risk for malpractice claims. Surgeons in the highest 10% for the negative behaviors of snapping at or talking down to others also were more likely to have malpractice claims. These results echo prior studies of physician behavior and malpractice risk. The authors suggest that addressing negative behaviors among surgeons could mitigate malpractice risk. A previous WebM&M commentary discussed patient complaints as safety surveillance.

Establishing a robust culture of safety, in which all staff feel free to voice concerns without fear of reprisal and leadership explicitly prioritizes safety, is crucial to safety improvement efforts. The most successful safety improvement programs have all explicitly prioritized enhancing safety culture. This study reports on the baseline results of a program that sought to improve surgical safety at hospitals in South Carolina. Safety culture was assessed among operating room personnel in 31 hospitals using a validated instrument. The investigators found a relatively robust association between better perceived safety culture and lower 30-day postoperative mortality. Studies in other clinical settings have found similar results. The hospitals involved in this study subsequently participated in a program to implement the Surgical Safety Checklist, which resulted in a significant improvement in mortality among participating hospitals compared to nonparticipating hospitals. A recent PSNet interview with Dr. Mary Dixon-Woods discussed the evolving concept of safety culture.

This qualitative study used data from free-text survey comments to examine the effectiveness of surgical safety checklist implementation at 11 hospitals. Although most operating room staff viewed the checklist positively, obtaining buy-in for consistent checklist use by all staff remained challenging.

Checklists have been shown to reduce surgical morbidity and mortality in randomized trials, but results of implementation in clinical settings have been mixed. This study reports on a voluntary, statewide collaborative program to implement a surgical safety checklist in South Carolina hospitals. Participating sites undertook a multifaceted process to support checklist implementation and culture change. Cross-institutional educational activities were available to all hospitals in the collaborative. Investigators determined that rates of surgical complications declined significantly in hospitals involved in the collaborative compared with those that did not participate, which had no change in postsurgical mortality over the same time frame. Past PSNet interviews with Lucian Leape and David Urbach discussed their perspectives on surgical safety checklists.

Checklists are widely utilized in health care to promote patient safety. Management of trauma patients is complex, and checklists may facilitate adherence to known standards of care. This pre–post study looked at the impact of the World Health Organization Trauma Care Checklist program across 11 hospitals in 9 countries. Researchers found that adherence to 18 out of 19 care process measures improved after the checklist program was implemented. Although investigators discerned no difference in mortality for the overall study population, they found a 50% reduction in mortality for patients with more severe trauma injuries after implementation of the program. A prior PSNet perspective discussed components of an effective checklist.

Although checklists have been shown to improve safety and surgical mortality, they can be difficult to implement, which limits their effectiveness in clinical practice. This study examined whether perceptions of teamwork predicted checklist performance. Trained observers used standardized tools to rate the extent of checklist completion and quality of teamwork. They found that checklists were implemented as intended in only 3% of cases. Surgical teams with better surgeon buy-in to checklists, clinical leadership, communication, and overall teamwork completed more checklist components. Clinical factors, including older patient age and longer duration of surgery, were also associated with performing more of the checklist. The authors suggest that teamwork is critical to checklist implementation. A PSNet interview discussed the challenges of implementing checklists in health care.

Surgical checklists have been associated with reduced morbidity and mortality in randomized trials, but real-world implementation has not always resulted in improvement. This pre-post study reports on an initiative to implement surgical checklists in South Carolina hospitals. Investigators surveyed surgical personnel before and after checklist implementation. Compared with the pre-intervention responses, measures of teamwork improved, and 54% of participants reported effective checklist compliance. The study did not report on changes in patient outcomes after checklist introduction, which would substantiate calls for implementing checklists widely. A PSNet interview with Dr. Lucian Leape discussed his perspective on checklists and patient safety.

In this survey of surgical teams at South Carolina hospitals that were implementing the World Health Organization's surgical safety checklist, the majority of overall responses about patient safety were positive. However, there was wide variation between hospitals. In some hospitals surveyed, up to 57% of respondents reported that they would not feel safe being treated in their own operating room.

The World Health Organization's surgical safety checklist has been successfully implemented in multiple clinical settings. This study, conducted in Moldova, found that checklist usage remained high 2 years after initial implementation, with postoperative complication rates continuing to decline over that time period.

The effectiveness of safety checklists depends mostly on how well they are implemented and performed—a recent study found no improvements in surgical outcomes with their adoption. This study created reliable observation tools for measuring surgical safety checklist performance and teamwork in the operating room.

Simulation training for operating room (OR) teams is an effective tool for improving teamwork and communication, but can be resource intensive and expensive. Due to these barriers, most simulation programs have only included trainees. For this study, a malpractice insurer provided the financial and administrative resources necessary to develop a standardized OR simulation training curriculum that involved active participation of attending surgeons and anesthesiologists. The group provided modest compensation for physicians' time and achieved wide participation. This teamwork curriculum covered principles of communication, assertiveness, and use of the WHO surgical safety checklist. Nearly all (93%) participants thought that the training would help them provide safer care. Dr. David Gaba discussed simulation training in a recent AHRQ WebM&M interview.

The business case for patient safety relies on the assumption that adverse events are financially harmful to hospitals over the long term, so up-front investment in safety improvement will eventually result in savings. However, this study cogently demonstrates that—at least for the specific case of surgical complications—hospitals actually profit when patients experience adverse events. Analysis of more than 30,000 surgical procedures revealed that hospitals received significantly greater net reimbursement for patients who experienced complications compared with those who had no complications. This disparity was particularly evident for patients with private insurance, although it was present to a lesser extent for patients with Medicare. This counterintuitive finding vividly demonstrates that, despite efforts such as the Centers for Medicare and Medicaid Services' policy of not paying for errors, payment incentives are not aligned to the extent that would truly encourage innovative approaches to improving safety. As the noted health economist Dr. Uwe Reinhart points out in his accompanying editorial, the findings of this study arise directly from a payment system that rewards providers for the volume rather than the quality of service provided.

This commentary reveals how implementing perioperative checklists in conjunction with the Safe Surgery 2015 initiative can promote a culture of safety in surgical care.