K. M. Masada1,2,3, K. T. Anderson1,2,3, M. Bartz-Kurycki1,2,3, J. E. Abraham1,2,3, J. Wang1,2,3, C. 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: Although the surgical safety checklists (SSC) were introduced to improve morbidity and mortality, the pre-incision, or “timeout” phase, may provide additional benefits such as preventing intra-operative delays in the era of cost containment and increasing evidence of increased risk of prolonged anesthesia in children. Checklists may provide a unique opportunity to communicate potential concerns to improve operating room efficiency as well as patient safety. The purpose of this study was to evaluate intra-operative delays and correlate them with adherence and fidelity to the pre-incision SSC.
Methods: Trained observers evaluated SSC compliance during 3 observation periods between 2014 and 2016. Adherence (verbalization of a checklist item) and fidelity (meaningful completion of a checklist item defined a priori) were evaluated. Delays, categorized as missing equipment, malfunctioning equipment, human error, and medication issues were captured. A total pre-incision score, combining number of checkpoints adhered to, was given to each case with a maximum score of 16. Six checkpoints were selected for fidelity assessment. Descriptive statistics, logistic regression and Student’s t-test were used to analyze results. A p-value <0.05 was significant.
Results: Of the 582 cases observed, 17% (n=98) had at least one documented intra-operative delay. There were 145 total documented delays, the majority of which were related to missing (48%, n=70) or malfunctioning (32%, n=47) equipment. Human error, such as dropped equipment or mislabeling led to only 14% (n=21) of delays, while medication-related issues were 5% (n=7). Compared to cases without delays, cases with delays did not have a different mean total pre-incision score in any year. Mean adherence to all checklist items was 93% compared to 78% mean fidelity. Five of 6 fidelity items had lower scores in delayed cases, while 2 checkpoints demonstrated significant association (graph). Equipment concerns had the largest differential in fidelity of more than 20%.
Conclusion: The pre-incision SSC is a communication tool, which offers an opportunity to discuss potential concerns and anticipated intra-operative needs. Mere adherence to the SSC does not appear to diminish intra-operative delays. However, meaningful completion (fidelity) to checklist items, especially those most likely to cause delays, such as equipment, may improve operating room efficiency and ultimately, patient safety.
