Surgical checklists: A systematic review of impacts and implementation

BMJ Quality and Safety

Volumn 23, Issue 4, 2014, Pages 299-318

  Treadwell, Jonathan R ^a   Lucas, Scott ^a   Tsou, Amy Y ^a  

^a ECRI INSTITUTE   (United States)

Author keywords

[No Author keywords available]

Indexed keywords

ADVERSE OUTCOME; CHECKLIST; CLINICAL EFFECTIVENESS; HEALTH HAZARD; HOSPITAL PERSONNEL; HUMAN; INTERPERSONAL COMMUNICATION; LEADERSHIP; OPERATING ROOM PERSONNEL; PATIENT SAFETY; PERIOPERATIVE PERIOD; POSTOPERATIVE COMPLICATION; REVIEW; SURGICAL CHECKLIST; SYSTEMATIC REVIEW; ADVERSE EFFECTS; MEDICAL ERROR; PREVENTION AND CONTROL; PROCEDURES; STANDARDS; SURGERY; UTILIZATION;

CHECKLIST; HUMANS; MEDICAL ERRORS; PATIENT SAFETY; SURGICAL PROCEDURES, OPERATIVE;

EID: 84896531270     PISSN: 20445415     EISSN: None     Source Type: Journal    
DOI: 10.1136/bmjqs-2012-001797     Document Type: Review

References (65)

1. Gawande AA, Thomas EJ, Zinner MJ, et al. The incidence and nature of surgical adverse events in Colorado and Utah in 1992. Surgery 1999;126:66-75.
2. Kable AK, Gibberd RW, Spigelman AD. Adverse events in surgical patients in Australia. Int J Qual Health Care 2002;14:269-76.
3. Neily J, Mills PD, Young-Xu Y, et al. Association between implementation of a medical team training program and surgical mortality. JAMA 2010;304:1693-700.
4. Arriaga AF, Bader AM, Wong JM, et al. Simulation-based trial of surgical-crisis checklists. N Engl J Med 2013;368:246-53.
5. 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. http://content. nejm.org/cgi/content/full/NEJMsa0810119
6. Facts about the Universal Protocol. Oakbrook Terrace, IL: The Joint Commission, 2004. http://www.jointcommission.org/assets/1/18/ Universal%20Protocol%201%204%20111.PDF (accessed 9 Jan 2008).
7. De Vries EN, Prins HA, Crolla RM, et al. Effect of a comprehensive surgical safety system on patient outcomes. N Engl J Med 2010;363:1928-37.
8. De Vries 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.
9. De Vries EN, Dijkstra L, Smorenburg SM, et al. The SURgical PAtient Safety System (SURPASS) checklist optimizes timing of antibiotic prophylaxis. Patient Saf Surg 2010;4:6.
10. De Vries EN, Eikens-Jansen MP, Hamersma AM, et al. Prevention of surgical malpractice claims by use of a surgical safety checklist. Ann Surg 2011;253:624-8.
11. Shekelle PG, Wachter RM, Pronovost PJ, et al. Making health care safer II: an updated critical analysis of the evidence for patient safety practices (prepared by the Southern California-RAND Evidence-based Practice Center under contract no. 290-2007-10062-I). Rockville, MD: Agency for Healthcare Research and Quality (AHRQ), 2013 (Comparative Effectiveness Review No 211). http://www.ahrq.gov/research/findings/evidence-based-reports/ptsafetyuptp.html
12. 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.
13. 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.
14. Yuan CT, Walsh D, Tomarken JL, et al. Incorporating the World Health Organization Surgical Safety Checklist into practice at two hospitals in Liberia. Jt Comm J Qual Patient Saf 2012;38:254-60.
15. Helmio P, Takala A, Aaltonen LM, et al. First year with WHO Surgical Safety Checklist in 7148 otorhinolaryngological operations: use and user attitudes. Clin Otolaryngol 2012;37:305-8.
16. Taylor B, Slater A, Reznick R. The surgical safety checklist effects are sustained, and team culture is strengthened. Surgeon 2010;8:1-4.
17. Greenberg CC, Regenbogen SE, Studdert DM, et al. Patterns of communication breakdowns resulting in injury to surgical patients. J Am Coll Surg 2007;204:533-40.
18. Griffen FD, Stephens LS, Alexander JB, et al. The American College of Surgeons' closed claims study: new insights for improving care. J Am Coll Surg 2007;204:561-9.
19. 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.
20. Mulloy DF, Hughes RG. Chapter 36. Wrong-site surgery: a preventable medical error. In: Patient safety and quality: an evidence-based handbook for nurses [AHRQ Publication No 08-0043]. Rockville, MD: Agency for Healthcare Research and Quality (AHRQ), 2008:1-15. http://www.ahrq.gov/qual/nurseshdbk/ docs/MulloyD-WSS.pdf
21. Using surgical checklists to comply with the Universal Protocol. Jt Comm Perspect Patient Saf 2011;11:9-11.
22. Quarterly update on preventing wrong-site surgery [draft]. Plymouth Meeting, PA: ECRI Institute, 2012:13.
23. Devine J, Chutkan N, Norvell DC, et al. Avoiding wrong site surgery: a systematic review. Spine 2010;35(9 Suppl):S28-36.
24. Sewell M, Adebibe M, Jayakumar P, et al. Use of the WHO Surgical Safety Checklist in trauma and orthopaedic patients. Int Orthop 2011;35:897-901.
25. Kearns RJ, Uppal V Bonner J, et al. The introduction of a surgical safety checklist in a tertiary referral obstetric centre. BMJ Qual Saf 2011;20:818-22.
26. Vats A, Vincent CA, Nagpal K, et al. Practical challenges of introducing WHO surgical checklist: UK pilot experience. BMJ 2010;340:133-5.
27. Fourcade A, Blache JL, Grenier C, et al. Barriers to staff adoption of a surgical safety checklist. BMJ Qual Saf 2012;21:191-7.
28. Conley DM, Singer SJ, Edmondson L, et al. Effective surgical safety checklist implementation. J Am Coll Surg 2011;212:873-9.
29. Styer KA, Ashley SW, Schmidt I, et al. Implementing the World Health Organization surgical safety checklist: a model for future perioperative initiatives. AORNJ 2011;94:590-8.
30. Bohmer AB, Wappler F, Tinschmann T, et al. The implementation of a perioperative checklist increases patients' perioperative safety and staff satisfaction. Acta Anaesthesiol Scand 2012;56:332-8.
31. Levy SM, Senter CE, Hawkins RB, et al. Implementing a surgical checklist: more than checking a box. Surgery 2012;152:331-36.
32. Vogts N, Hannam JA, Merry AF, et al. Compliance and quality in administration of a Surgical Safety Checklist in a tertiary New Zealand hospital. NZ Med J 2011;124:48-58.
33. Van Klei WA, Hoff RG, Van Aarnhem EE, et al. Effects of the introduction of the WHO 'Surgical Safety Checklist' on in-hospital mortality: a cohort study. Ann Surg 2012;255:44-9.
34. Kasatpibal N, Senaratana W, Chitreecheur J, et al. Implementation of the World Health Organization Surgical Safety Checklist at a university hospital in Thailand. Surg Infect (Larchmt) 2012;13:50-6.
35. Askarian M, Kouchak F, Palenik CJ. Effect of surgical safety checklists on postoperative morbidity and mortality rates, Shiraz, Faghihy Hospital, a 1-year study. Qual Manag Health Care 2011;20:293-7.
36. Anonymous. Communicating for success: Royal Bolton Hospital NHS Foundation Trust introduces the Surgical Safety Checklist. JPerioper Pract 2010;20:85-6.
37. Garnerin P, Ares M, Huchet A, et al. Verifying patient identity and site of surgery: improving compliance with protocol by audit and feedback. Qual Saf Health Care 2008;17:454-8.
38. Nilsson L, Lindberget O, Gupta A, et al. Implementing a preoperative checklist to increase patient safety: a 1-year follow-up of personnel attitudes. Acta Anaesthesiol Scand 2010;54:176-82.
39. Owers C, Lees E, Roberts J. Correct site surgery-are we up to standard? Cent Eur J Med 2010;5:407-10.
40. Follow-up survey on Universal Protocol. Oakbrook Terrace, IL: The Joint Commission, 2010. http://www.jointcommission.org/follow-up-survey-universal- protocol/(accessed 18 Oct. 2011).
41. Semel ME, Resch S, Haynes AB, et al. Adopting a surgical safety checklist could save money and improve the quality of care in U. S. hospitals. Health Aff (Millwood) 2010;29:1593-9.
42. Mahajan RP The WHO Surgical Checklist. Best Pract Res Clin Anaesthesiol 2011;25:161-8.
43. The objectives and study aim of the Surgical Checklist Implementation Project. London, UK: Imperial College, 2010. http://www.safesurgery.org.uk/ (accessed 6 Oct. 2011).
44. Robbins J. Hospital checklists. Transforming evidence-based care and patient safety protocols into routine practice. Crit Care Nurs Q 2011;34:142-9.
45. Warnock GL. Of surgeons and safety checklists. Can J Surg 2010;53:364-6.
46. Anonymous. National push for surgical safety checklist under way. Hosp Peer Rev 2009;34:53-7.
47. Grande L. Improving safety in the operating room reduces hospital mortality. Cir Esp 2009;86:329-30.
48. Anonymous. WHO's patient-safety checklist for surgery. Lancet 2008;372:1.
49. Gough I. A surgical safety checklist for Australia and New Zealand. ANZ J Surg 2010;80:1-2.
50. Sivathasan N, Rakowski KR, Robertson BF, et al. The World Health Organization's 'Surgical Safety Checklist': should evidence-based initiatives be enforced in hospital policy? JRSM Short Rep 2010;1:40.
51. Patterson P In survey, about half of ORs are using the WHO checklist. OR Manager 2009;25:1, 6-8.
52. Abdel-Galil K. The WHO Surgical Safety Checklist: are we measuring up. Br J Oral Maxillofac Surg 2010;48:397-8.
53. Singer SJ. Grants awarded in FY 2010. Factors associated with effective implementation of a surgical safety checklist. In: Researching implementation and change while improving quality: grant awards. Fact sheet. Rockville, MD: Agency for Healthcare Research and Quality (AHRQ), 2011:3. http://www.ahrq.gov/ qual/qualimp.pdf
54. Safe surgery saves lives. Geneva: World Health Organization. http://www.who.int/patientsafety/safesurgery/en/(accessed 22 Sep. 2011).
55. Helmio P, Blomgren K, Takala A, et al. Towards better patient safety: WHO Surgical Safety Checklist in otorhinolaryngology Clin Otolaryngol 2011;36:242-7.
56. Bell R, Pontin L. How implementing the surgical safety checklist improved staff teamwork in theatre. Nurs Times 2010;106:12.
57. Bell R. Implementing the surgical safety checklist at Guy's and St Thomas'. London: Patient Safety First. http://www.patientsafetyfirst.nhs.uk/ Content.aspx?path=/interventions/CasestudyGuys/(accessed 6 Oct. 2011).
58. Sparkes D, Rylah B. The World Health Organization Surgical Safety Checklist. Br J Hosp Med (Lond) 2010;71:276-80.
59. Norton EK, Rangel SJ. Implementing a pediatric surgical safety checklist in the OR and beyond. AORN J 2010;92:61-71.
60. Bittle M. Theatre team learns to use checklist to make surgery safer. Nurs N Z 2011;17:16-7.
61. Howie WO, Dutton RP Implementation of an evidence-based extubation checklist to reduce extubation failure in patients with trauma: a pilot study. AANAJ 2012;80:179-84.
62. Perez-Guisado J, De Haro-Padilla JM, Rioja LF. Implementation of the World Health Organization Surgical Safety Checklist in plastic and reconstructive patients. Plast Reconstr Surg 2012;129:600e-2e.
63. Takala RS, Pauniaho SL, Kotkansalo A, et al. A pilot study of the implementation of WHO Surgical Checklist in Finland: improvements in activities and communication. Acta Anaesthesiol Scand 2011;55:1206-14.
64. Truran P, Critchley RJ, Gilliam A. Does using the WHO Surgical Checklist improve compliance to venous thromboembolism prophylaxis guidelines. Surgeon 2011;9:309-11.
65. Anonymous. Checklists help clarify Universal Protocol steps: simple tools help organize staff and equipment before the procedure begins. Brief Patient Saf 2007;8(2):1-3.