I. Solsky1, J. Lagoo1, W. Berry1,2, J. Baugh3, L. A. Edmondson1, S. Singer2, A. B. Haynes1,4,5 1Ariadne Labs,Boston, MA, USA 2Harvard School Of Public Health,Department Of Health Policy And Management,Boston, MA, USA 3University Of California – Los Angeles,Department Of Emergency Medicine,Los Angeles, CA, USA 4Harvard School Of Medicine,Surgery,Brookline, MA, USA 5Massachusetts General Hospital,Department Of Surgery,Boston, MA, USA
Introduction: Adopted by thousands of hospitals globally, the World Health Organization’s (WHO) Surgical Safety Checklist is meant to be modified to best serve local practice but little is known about the type of changes that are made. The goal of this study is to provide a descriptive analysis of the extent and content of checklist modification.
Methods: Non-subspecialty surgical checklists in English were obtained through online search along with targeted requests sent to hospitals. A detailed coding scheme was created to capture modifications to checklist content and formatting. Overall checklist information was collected such as the total number of lines of text and the team members explicitly mentioned. Information was also collected on modifications made to individual items and which were most frequently deleted. New items added were also captured. Descriptive statistics were performed.
Results: 161 checklists from 17 US states (n=116) and 11 countries (n=45) were analyzed. Every checklist was modified. Compared to the WHO checklist, those in our sample contained more lines of text (median: 63 (IQR: 50-73; Range: 14-216) vs. 56) and more items (36 (IQR: 30-43; Range: 14-80) vs. 28). Checklists added a median of 13 new items (IQR: 8-21, Range: 0-57). Items most frequently added referenced implants/special equipment (added by 83.23% of checklists), DVT prophylaxis/anticoagulation (74.53%), patient positioning (62.73%), and an opportunity to voice questions/concerns (55.28%). Despite increasing in size, checklists removed a median of 5 WHO items (IQR: 2-8; Range: 0-19). The most frequently removed items were the pulse oximeter check (removed in 75.16% of checklists), the articulation of patient-specific concerns from the nurse (47.83%) or anesthetist (38.51%), and the surgeon-led discussion of anticipated blood loss (45.96%) or case duration (42.24%), the latter 4 items comprising part of the WHO checklist’s 7-item “Anticipated Critical Events” section, which is intended for the exchange of critical information. The surgeon was not explicitly mentioned as participating in any part of the checklist in 14.29% of checklists; the anesthesiologist/CRNA in 14.91%, the circulator in 9.94%, and the scrub in 77.64%.
Conclusion: As encouraged by the WHO, checklists are highly modified. However, many are enlarged with additional lines and items that may not prompt discussion or encourage teamwork. Of particular concern is the frequent removal of items from the WHO’s “Anticipated Critical Events” section, which is central to the checklist’s efforts to prevent complications by giving all team members an opportunity to voice concerns together. Leadership involved in checklist creation should ensure that checklists can be easily implemented, are inclusive of all team members, and promote a culture of safety. Further research is needed to assess the clinical impact of checklist modifications.