Safety checklist compliance and a false sense of safety: New directions for research

BMJ Quality and Safety

Volumn 23, Issue 3, 2014, Pages 183-186

  Rydenfält, Christofer ^a,c   Ek, Åsa ^a   Larsson, Per Anders ^b  

^a LUND UNIVERSITY   (Sweden)

^b HELSINGBORG HOSPITAL   (Sweden)

^c Faculty of Engineering   (Sweden)

Author keywords

[No Author keywords available]

Indexed keywords

CHECKLIST; HEALTH CARE QUALITY; HUMAN; MORTALITY; PATIENT SAFETY; STANDARDS; SURGERY; THEORETICAL MODEL; WORLD HEALTH ORGANIZATION;

CHECKLIST; HUMANS; MODELS, THEORETICAL; PATIENT SAFETY; QUALITY ASSURANCE, HEALTH CARE; SURGICAL PROCEDURES, OPERATIVE; WORLD HEALTH ORGANIZATION;

EID: 84894170039     PISSN: 20445415     EISSN: None     Source Type: Journal    
DOI: 10.1136/bmjqs-2013-002168     Document Type: Note

References (26)

1. de Vries E, Prins H, Crolla R, et al. Effect of a comprehensive surgical safety system on patient outcomes. N Engl J Med 2010;363:1928-37.
2. Weiser TG, Haynes AB, Dziekan G, et al. Effect of a 19-item surgical safety checklist during urgent operations in a global patient population. Ann Surg 2010;251:976-80.
3. Haynes AB, Weiser TG, Berry WR, et al. A surgical safety checklist to reduce morbidity and mortality in a global population. N Engl J Med 2009;360:491-9.
4. Pronovost P, Needham D, Berenholtz S, et al. An intervention to decrease catheter-related bloodstream infections in the ICU. N Engl J Med 2006;355:2725-32.
5. WHO. Implementation manual WHO surgical safety checklist 1st edition-safe surgery saves lives. Geneva: World Health Organization, 2008
6. DeVries EN, Hollmann MW, Smorenburg SM,et al. Development and validation of the SURgical PAtient Safety System (SURPASS) checklist. Qual Saf Health Care, 2009. 18, 121-6.
7. Cullati S, Le Du S, Raë A-C, et al. Is the surgical safety checklist successfully conducted' An observational study of social interactions in the operating rooms of a tertiary hospital. BMJ Qual Saf 2013;22:639-46.
8. Rydenfält C, Johansson G, Odenrick P, et al. Compliance with the WHO surgical safety checklist: deviations and possible improvements. Int J Qual Health Care 2013;25:182-7.
9. Levy SM, Senter CE, Hawkins RB, et al. Implementing a surgical checklist: more than checking a box. Surgery 2012;152:331-6.
10. Vogts N, Hannam JA, Merry AF, et al. Compliance and quality in administration of a surgical safety checklist in a tertiary New Zealand hospital. N Z Med J 2011;124:48-58.
11. Reason J. Managing the risks of organizational accidents. Aldershot: Ashgate, 1997.
12. de Vries EN, Prins HA, Bennink MC, et al. Nature and timing of incidents intercepted by the SURPASS checklist in surgical patients. BMJ Qual Saf 2012;21:503-8.
13. Hollnagel E. Barriers and accident prevention. Aldershot, Hampshire, England: Ashgate, 2004.
14. Borchard A, Schwappach DLB, Barbir A, et al. A systematic review of the effectiveness, compliance, and critical factors for implementation of safety checklists in surgery. Ann Surg 2012;256:925-33.
15. Nilsson L, Lindberget O, Gupta A, et al. Implementing a pre-operative checklist to increase patient safety: a 1-year follow-up of personnel attitudes. Acta Anaesthesiol Scand 2010;54:176-82.
16. Haynes AB, Weiser TG, Berry WR, et al. Changes in safety attitude and relationship to decreased postoperative morbidity and mortality following implementation of a checklist-based surgical safety intervention. BMJ Qual Saf 2011; 20:102-7.
17. Haugen AS, SØfteland E, Eide GE, et al. Impact of the World Health Organization's surgical safety checklist on safety culture in the operating theatre: a controlled intervention study. Br J Anaesth 2013;110:807-15.
18. Carlile PR. Transferring, translating, and transforming: an integrative framework for managing knowledge across boundaries. Organization Science 2004;15:555-68.
19. Rasmussen J. Risk management in a dynamic society: a modelling problem. Saf Sci 1997;27:183-213.
20. Cook R, Rasmussen J. "Going solid": a model of system dynamics and consequences for patient safety. Qual Saf Health Care 2005;14:130-4.
21. Patterson ES, Rogers ML, Chapman RJ, et al. Compliance with intended use of bar code medication administration in acute and long-term care: an observational study. Hum Factors 2006;48:15-22.
22. Hollnagel E. The ETTO principle: efficiency-thoroughness trade-off-why things that go right sometimes go wrong. Farnham: Ashgate, 2009.
23. Odom-Forren J. The normalization of deviance: a threat to patient safety. J Perianesth Nurs 2011;26:216-9.
24. Banja J. The normalization of deviance in healthcare delivery. Bus Horiz 2010;53:139-48.
25. Vaughan D. The Challenger launch decision: risky technology, culture, and deviance at NASA. Chicago: University of Chicago Press, 1996.
26. Amalberti R, Vincent C, Auroy Y, et al. Violations and migrations in health care: a framework for understanding and management. Qual Saf Health Care 2006; 15(Suppl I):66-71.