J. Wang1,2,3, K. T. Anderson1,2,3, M. Bartz-Kurycki1,2,3, K. M. Masada1,2,3, J. E. Abraham1,2,3, C. K. Shoraka1,2,3, M. T. Austin1,2,3, A. L. Kawaguchi1,2,3, K. P. Lally1,2,3, K. Tsao1,2,3 1McGovern Medical School, The University Of Texas Health Sciences Center At Houston,Houston, TX, USA 2Children’s Memorial Hermann Hospital,Pediatric Surgery,Houston, TX, USA 3Center For Surgical Trials And Evidence-based Practices (C-STEP),Houston, TX, USA
Introduction: In 2008, the World Health Organization published guidelines for implementation of a 3 phase Surgical Safety Checklist (SSC) with the goal of reducing patient harm due to surgical care. We previously demonstrated high checklist performance (>95% adherence) of the pre-incision, or “timeout” phase through a stakeholder-driven, iterative process including annual mandatory education on checklist and OR safety for all surgical team members. We recently introduced three new checkpoints to improve OR safety (establishing safe zone, fire risk and plan, maximum allowable dose of on-field medications). We hypothesized that mere inclusion of new checkpoints would demonstrate high adherence and fidelity (meaningful completion) when incorporated into an already high functioning pre-incisional checklist performance.
Methods: Trained observers, using a priori definitions, documented surgical team adherence for the pre-incision checklist during 3 periods between 2014 and 2016. Fidelity – a measure of complex completion of a checklist point requiring inter-team communication and coordination above simple verbalization – was recorded for 6 checkpoints during all years. Three new checkpoints, establishment of a safe zone for sharps, discussion of fire risk and plan and description (concentration, maximum dose) of field medications, were introduced prior to the 2016 observation period. Fidelity was assessed by checkpoint and surgical specialty. Interrater reliability was evaluated using Cohen’s kappa. Kruskal-Wallis test by ranks and Student’s t-test were used to evaluate variation in fidelity. A p-value <0.05 was significant.
Results: 277 pediatric surgical operation pre-incision checklists were observed across 9 specialties in 2016, 211 cases in 2015, and 207 cases in 2014. Interrater reliability was greater than 0.70 for all years. Average fidelity for the 6 checkpoints evaluated during all observation periods increased between 2014 and 2016 (from 71% to 92%, p<0.01). All but one the specialties, Dental surgery, which was not observed during 2016, improved their fidelity significantly (figure). Fidelity was significantly lower than the 2016 average for the 3 new pre-incision checkpoints (safe zone fidelity= 79%, fire risk fidelity= 83%, field medication fidelity= 38%, all p<0.01).
Conclusion: Overall meaningful pre-incision checklist performance has improved annually from 2014-2016. However, new checklist items without strategic implementation strategies demonstrate lower fidelity. Changes to established processes require targeted intervention to maintain high performance.
