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Journal Article > Study
A qualitative evaluation of the barriers and facilitators toward implementation of the WHO surgical safety checklist across hospitals in England: lessons from the "Surgical Checklist Implementation Project."
Russ SJ, Sevdalis N, Moorthy K, et al. Ann Surg. 2015;261:81-91.
The initial introduction of the World Health Organization surgical safety checklist was associated with impressive improvements in patient safety. However, more recently a study of the government-supported implementation of the checklist in Canada showed no beneficial effect. This study examined the mandated introduction of the surgical safety checklist in hospitals across England and discovered large variation in how the checklist was initially implemented. The most common barrier encountered was resistance from senior clinicians. The authors provide generalizable recommendations to guide the future implementation of improvement efforts. A recent AHRQ WebM&M interview with Dr. Lucian Leape discussed his perspective on the effect and implementation of checklists for patient safety.
Journal Article > Study
Effect of the World Health Organization checklist on patient outcomes: a stepped wedge cluster randomized controlled trial.
Haugen AS, Søfteland E, Almeland SK, et al. Ann Surg. 2015;261:821-828.
Initial enthusiasm about the ability of the World Health Organization's surgical safety checklist to prevent harm was tempered by a subsequent study that failed to improve clinical or safety outcomes. The conflicting results of surgical checklist studies have led to concerns that checklists may lack effectiveness when care is of relatively high quality at baseline, and that poor implementation can hinder their use. In this study, the WHO checklist proved successful at improving safety outcomes when implemented across five surgical services at two academic hospitals in Norway. The checklist's success in this rigorously designed and analyzed study was likely attributable to the institution having followed a structured implementation process that had been previously demonstrated to improve safety culture in the operating room. The controversy around surgical safety checklists is discussed in a recent AHRQ WebM&M interview.
Maxfield D, Grenny J, Lavandero R, Groah L. Provo, UT: VitalSmarts; 2011.
Silence Kills was a 2005 report that highlighted communication failures that contribute to patient harm. These included broken rules, poor teamwork, and disruptive behaviors. This report builds on those findings based on a survey of more than 6500 nurses and nurse managers. Key findings suggested that existing safety tools, such as checklists, are not in themselves solutions to these communication failures. Nurses identified dangerous shortcuts, incompetence, and disrespect as three concerns that undermine systems designed to provide safer care. A past AHRQ WebM&M perspective and interview discuss the role of checklists in health care settings.
Journal Article > Study
Neily J, Mills PD, Young-Xu Y, et al. JAMA. 2010;304:1693-1700.
Classic studies have demonstrated that operating rooms are rife with communication and teamwork problems, and suboptimal teamwork has been linked to poor postoperative patient outcomes. In this rigorously designed study, surgical teams at 74 Veterans Affairs (VA) hospitals underwent teamwork training through the VA's Medical Team Training program. The training also included implementation of preoperative and postoperative checklists. The teamwork training was associated with a striking reduction in mortality compared to other VA hospitals that had not yet implemented the program, and a dose–response effect was also evident, with continuing training resulting in further reductions in mortality. An accompanying editorial lauds this study as an example of how to conduct a rigorous, evidence-based evaluation of a safety intervention, and stresses that addressing teamwork and safety culture are as essential to improving safety as technical and procedural interventions such as checklists.
Journal Article > Review
Rivera-Rodriguez AJ, Karsh BT. Qual Saf Health Care. 2010;19:304-312.
The majority of individual errors are due to failure to perform automatic or reflexive actions. A major risk factor for these "slips" is being interrupted or distracted while performing a task. This review examined the literature on the incidence, risk factors, and effects of interruptions in several clinical settings, ranging from outpatient clinics to the operating room. Although distractions are common and may be associated with increased risk for error, particularly if they occur during medication administration or signout, the authors point out that many interruptions may be necessary to communicate urgent clinical information. They argue for complexity theory–based research to delineate the harmful and beneficial aspects of interruptions, rather than for interventions that seek to simply eliminate interruptions. Checklists have been widely adopted as a means of preventing errors of omission, which may be precipitated by interruptions.