J. E. Abraham1,2,3, K. T. Anderson1,2,3, M. A. Bartz-Kurycki1,2,3, K. M. Masada1,2,3, C. K. Shoraka1,2,3, J. Wang1,2,3, A. L. Kawaguchi1,2,3, K. P. Lally1,2,3, K. Tsao1,2,3 1McGovern Medical School, University Of Texas Health Science Center At Houston,Houston, TX, USA 2Children’s Memorial Hermann Hospital,Houston, TX, USA 3Center For Surgical Trials And Evidence-based Practices (C-STEP),The University Of Texas Health Sciences Center At Houston,Houston, TX, USA
Introduction: The effectiveness of the surgical safety checklist (SSC) has recently been questioned. Possibilities for failure include low adherence to checkpoints and poor fidelity or meaningful completion. The debriefing phase of the SSC provides the operative team an opportunity to share pertinent intra-operative information and to communicate post-operative plans. We developed a stakeholder-driven SSC and achieved >95% adherence to the pre-incision phase checkpoints. However, the debriefing phase has yet to be evaluated. The purpose of this study is to assess the current state of adherence to the debrief checklist in our institution to identify areas for improvement.
Methods: A direct observational study was conducted from 2014-2016 in an academic children’s hospital. Direct observations of debriefings were performed annually over eight-week periods. Convenience sampling of cases was performed across 9 pediatric surgical specialties. During the 8-point debrief checklist, trained observers documented team members’ adherence to a priori defined checkpoints. Inter-rater reliability (kappa) was performed for checklist adherence. Descriptive statistics and the Kruksal-Wallis rank test were utilized (p <0.05 was significant).
Results: Over a three-year period, 654 debriefings were observed (2014 n=205; 2015 n=198; 2016 n=251). Interrater reliability for all intervals was >0.65. Overall, the debriefing checklist was conducted in 91%, 91%, and 95% of cases each year, respectively. The mean number of checklist items completed increased over time with 6.2, 6.5, and 6.6 out of 8, respectively (p=0.03). Nonetheless, half of cases did not fully complete the debriefing checklist and 9% did not debrief at all in 2014 and 2015 with 6% in 2016. The checklist items with lowest adherence and no improvement over time were identification and labeling of specimen, discussion of wound class, confirmation of correct instrument and needle counts, and discussion of equipment problems. Significant improvement was noted in the following checkpoints: surgery attending present for debrief, discussion of blood loss and transfusions, and discussion of intra-operative concerns and post-operative plans (figure).
Conclusion: There has been a slight increase in overall adherence to the post-operative debrief from 2014-2016; however, much work needs to be done to improve performance of each and every checklist item. Lack of checklist effectiveness may be due to poor adherence. Future efforts will include targeted interventions to ameliorate adherence to the debriefing phase and evaluate opportunities to improve patient safety and increase efficiency in the operating room.
