Barriers and facilitators related to the implementation of surgical safety checklists: A systematic review of the qualitative evidence

BMJ Quality and Safety

Volumn 24, Issue 12, 2015, Pages 776-786

  Bergs, Jochen ^a   Lambrechts, Frank ^a   Simons, Pascale ^a   Vlayen, Annemie ^a   Marneffe, Wim ^a   Hellings, Johan ^a,b   Cleemput, Irina ^c   Vandijck, Dominique ^a,d,e  

^a HASSELT UNIVERSITY   (Belgium)

^b AZ Delta   (Belgium)

^c BELGIAN HEALTH CARE KNOWLEDGE CENTRE KCE   (Belgium)

^d GHENT UNIVERSITY   (Belgium)

^e GHENT UNIVERSITY HOSPITAL   (Belgium)

Author keywords

[No Author keywords available]

Indexed keywords

CHECKLIST; COOPERATION; EXPECTATION; HEALTH CARE PERSONNEL; HUMAN; INTERPERSONAL COMMUNICATION; MEDLINE; NURSE; OPERATING ROOM; OPERATING ROOM PERSONNEL; PATIENT SAFETY; PERCEPTION; QUALITATIVE RESEARCH; REVIEW; SURGEON; SURGICAL SAFETY; SYSTEMATIC REVIEW; TEAMWORK; IN SERVICE TRAINING; LEADERSHIP; ORGANIZATION AND MANAGEMENT; STANDARDS; WORKFLOW;

CHECKLIST; COMMUNICATION; HUMANS; INSERVICE TRAINING; LEADERSHIP; OPERATING ROOMS; PATIENT SAFETY; PERCEPTION; QUALITATIVE RESEARCH; WORKFLOW;

EID: 84942330903     PISSN: 20445415     EISSN: None     Source Type: Journal    
DOI: 10.1136/bmjqs-2015-004021     Document Type: Review

References (94)

1. Bergs J, Hellings J, Simons PAM, et al. Surgical safety checklists: an update. Acta Chir Belg 2014;114:219-24.
2. 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.
3. 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.
4. 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.
5. 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.
6. Bliss LA, Ross-Richardson CB, Sanzari LJ, et al. Thirty-day outcomes support implementation of a surgical safety checklist. J Am Coll Surg 2012;215:766-76.
7. Kwok AC, Funk LM, Baltaga R, et al. Implementation of the World Health Organization Surgical Safety Checklist, Including Introduction of Pulse Oximetry, in a Resource-Limited Setting. Ann Surg 2013;257:633-9.
8. de Vries EN, Prins HA, Crolla RMPH, et al. Effect of a comprehensive surgical safety system on patient outcomes. N Engl J Med 2010;363:1928-37.
9. 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.
10. Bergs J, Vandijck D. Systematic review and meta-analysis of the effect of the World Health Organization surgical safety checklist on postoperative complications. Br J Surg 2014;101:150-8.
11. Urbach DR, Govindarajan A, Saskin R, et al. Introduction of surgical safety checklists in Ontario, Canada. N Engl J Med 2014;370:1029-38.
12. Reames BN, Krell RW, Campbell DA, et al. A checklist-based intervention to improve surgical outcomes in michigan: evaluation of the keystone surgery program. JAMA Surg 2015;150:208-15.
13. Reames BN, Scally CP, Thumma JR, et al. Evaluation of the effectiveness of a surgical checklist in medicare patients. Med Care 2015;53:87-94.
14. van Klei WA, Hoff RG, Van Aarnhem EEHL, 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.
15. Vats A, Vincent CA, Nagpal K, et al. Practical challenges of introducing WHO surgical checklist: UK pilot experience. BMJ 2010;340:b5433.
16. Morgan L, Pickering SP, Hadi M, et al. A combined teamwork training and work standardisation intervention in operating theatres: controlled interrupted time series study. BMJ Qual Saf 2015;24:111-19.
17. Bergs J, Verelst S, Gillet J-B, et al. Evaluating implementation of the emergency severity index in a belgian hospital. J Emerg Nurs 2014;40:592-7.
18. Simons PAM, Houben RMA, Backes HH, et al. Compliance to technical guidelines for radiotherapy treatment in relation to patient safety. Int J Qual Health Care 2010;22:187-93.
19. Blot K, Bergs J, Vogelaers D, et al. Prevention of central line-associated bloodstream infections through quality improvement interventions: A systematic review and meta-analysis. Clin Infect Dis 2014;59:96-105.
20. Borchard A, Schwappach DL, Barbir A, et al. A Systematic review of the effectiveness, compliance, and critical factors for implementation of safety checklists in surgery. Ann Surg 2012;265:925-33.
21. Saturno PJ, Soria-Aledo V, Da Silva Gama ZA, et al. Understanding WHO surgical checklist implementation: tricks and pitfalls. An observational study. World J Surg 2014;38:287-95.
22. Hannam JA, Glass L, Kwon J, et al. A prospective, observational study of the effects of implementation strategy on compliance with a surgical safety checklist. BMJ Qual Saf 2013;22:940-7.
23. Smythe WR. Surgical Safety Checklist compliance: A job done poorly! J Am Coll Surg 2013;217:867-73.e1-3.
24. Morgan PJ, Cunningham L, Mitra S, et al. Surgical safety checklist: implementation in an ambulatory surgical facility. Can J Anaesth 2013;60:528-38.
25. Braaf S, Manias E, Riley R. The "time-out" procedure: an institutional ethnography of how it is conducted in actual clinical practice. BMJ Qual Saf 2013;22:647-55.
26. Poon SJ, Zuckerman SL, Mainthia R, et al. Methodology and bias in assessing compliance with a surgical safety checklist. Jt Comm J Qual Patient Saf 2013;39:77-82.
27. 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.
28. Levy SM, Senter CE, Hawkins RB, et al. Implementing a surgical checklist: more than checking a box. Surgery 2012;152:331-6.
29. Vogts N, Hannam JA, Mitchell SJ. Compliance and quality in administration of a Surgical Safety Checklist in a tertiary New Zealand hospital. N Z Med J 2011;124:48-58.http://eutils.ncbi. nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&id= 21963925&retmode=ref&cmd=prlinks
30. Thomas J, Harden A. Methods for the thematic synthesis of qualitative research in systematic reviews. BMC Med Res Methodol 2008;8:45.
31. Shaw RL, Booth A, Sutton AJ, et al. Finding qualitative research: an evaluation of search strategies. BMC Med ResMethodol 2004;4:5-5.
32. Pearson M, Moxham T, Ashton K. Effectiveness of search strategies for qualitative research about barriers and facilitators of program delivery. Eval Health Prof 2011;34:297-308.
33. Hannes K. Chapter 4: critical appraisal of qualitative research. In: Noyes J, Booth A, Hannes K, et al., eds. Supplementary guidance for inclusion of qualitative research in Cochrane Systematic Reviews of Interventions. Version 1 (updated August 2011). Cochrane Collaboration Qualitative Methods Group, 2011:1-14.
34. Hannes KK, Lockwood CC, Pearson AA. A comparative analysis of three online appraisal instruments' ability to assess validity in qualitative research. Qual Health Res 2010;20:1736-43.
35. The Joanna Briggs Institute. Joanna Briggs Institute Reviewers' Manual: 2014 edition. The Joanna Briggs Institute, 2014.
36. Dixon-Woods M, Bonas S, Booth A, et al. How can systematic reviews incorporate qualitative research? A critical perspective. Qual Res 2006;6:27-44.
37. Daly J, Willis K, Small R, et al. A hierarchy of evidence for assessing qualitative health research. J Clin Epidemiol 2006;60:43-9.
38. QSR International Pty Ltd. NVivo qualitative data analysis software.
39. Verdaasdonk EGG, Stassen LPS, Widhiasmara PP, et al. Requirements for the design and implementation of checklists for surgical processes. Surg Endosc 2009;23:715-26.
40. Paull DE, Mazzia LM, Izu BS, et al. Predictors of successful implementation of preoperative briefings and postoperative debriefings after medical team training. Am J Surg 2009;198:675-8.
41. Sivathasan N, Rakowski KRM, Robertson BFM, et al. The World Health Organization's 'Surgical Safety Checklist': should evidence-based initiatives be enforced in hospital policy? JRSM Short Rep 2010;1:40-0.
42. Robinson LD, Paull DE, Mazzia LM, et al. The role of the operating room nurse manager in the successful implementation of preoperative briefings and postoperative debriefings in the VHA Medical Team Training Program. J Perianesth Nurs 2010;25:302-6.
43. Weiser TG, Lipsitz SR, Dziekan G, 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 2010;20:102-7.
44. Thomassen O, Espeland A, Søfteland E, et al. Implementation of checklists in health care; learning from high-reliability organisations. Scand J Trauma Resusc Emerg Med 2011;19:53-3.
45. Lingard L, Regehr G, Orser B, et al. Evaluation of a preoperative checklist and team briefing among surgeons, nurses, and anesthesiologists to reduce failures in communication. Arch Surg 2008;143:12-17-discussion 18.
46. AliM, Osborne A, Bethune R, et al. Preoperative surgical briefings do not delay operating room start times and are popular with surgical team members. J Patient Saf 2011;7:139-43.
47. Calland JF. Surgical safety checklists are an effective means for reducing surgical morbidity and mortality, but have we gone far enough in team-building and leadership to create high reliability? Evid Based Med 2013;18:235-6.
48. Styer KA, Ashley SW, Schmidt I, et al. Implementing the World Health Organization surgical safety checklist: A model for future perioperative initiatives. AORN journal 2011;94:590-8.
49. Delgado Hurtado JJ, Jiménez X, Peñalonzo MA, et al. Acceptance of the WHO Surgical Safety Checklist among surgical personnel in hospitals in Guatemala city. BMC Health Serv Res 2012;12:169.
50. Bragg K, Schlenk EA, Wolf G, et al. Time out! Surveying surgical barriers. Nurs Manage 2012;43:38-44.
51. Helmio P, Takala A, Aaltonen L-M, et al. First year with WHO Surgical Safety Checklist in 7148 otorhinolaryngological operations: use and user attitudes. Clin Otolaryngol 2012;37:305-8.
52. Sheena Y, Fishman JM, Nortcliff C, et al. Achieving flying colours in surgical safety: audit of World Health Organization "Surgical Safety Checklist" compliance. J Laryngol Otol 2012;126:1049-55.
53. Haugen AS, Murugesh S, Haaverstad R, et al. A survey of surgical team members' perceptions of near misses and attitudes towards Time Out protocols. BMC Surg 2013;13:46-6.
54. Pickering SP, Robertson ER, Griffin D, et al. Compliance and use of the World Health Organization checklist in U.K. operating theatres. Brit J Surg 2013;100:1664-70.
55. Cullati S, Licker M-J, Francis P, et al. Implementation of the surgical safety checklist in Switzerland and perceptions of its benefits: cross-sectional survey. PLoS ONE 2013;9:e101915.
56. van Schoten SM, Kop V, de Blok C, et al. Compliance with a time-out procedure intended to prevent wrong surgery in hospitals: results of a national patient safety programme in the Netherlands. BMJ Open 2014;4:e005075.
57. Norton EK, Rangel SJ. Implementing a pediatric surgical safety checklist in the OR and beyond. AORN J 2010;92:61-71.
58. Putnam LR, Levy SM, Sajid M, et al. Multifaceted interventions improve adherence to the surgical checklist. Surgery 2014;156:336-44.
59. Patel J, Ahmed K, Guru KA, et al. An overview of the use and implementation of checklists in surgical specialities-A systematic review. Int J Surg 2014;12:1317-23.
60. Sendlhofer G, Mosbacher N, Karina L, et al. Implementation of a surgical safety checklist: interventions to optimize the process and hints to increase compliance. PLoS ONE 2014;10: e0116926.
61. Lingard L, Espin S, Rubin B, et al. Getting teams to talk: development and pilot implementation of a checklist to promote interprofessional communication in the OR. Qual Saf Health Care 2005;14:340-6.
62. Gillespie BM, Chaboyer W, Wallis M, et al. Why isn't 'time out' being implemented? An exploratory study. Qual Saf Health Care 2010;19:103-6.
63. Thomassen O, Brattebø G, Heltne J-K, et al. Checklists in the operating room: Help or hurdle? A qualitative study on health workers' experiences. BMC Health Serv Res 2010;10: 342-2.
64. Conley DM, Singer SJ, Edmondson L, et al. Effective surgical safety checklist implementation. J Am Coll Surg 2011;212:873-9.
65. Cunat C, Flatin V, Viale J-P. Implementation strategy of the HAS French surgical check-list in a university hospital. Ann Fr Anesth Reanim 2011;30:484-8.
66. Wæhle HV, Søfteland E, Hjälmhult E. Adjusting team involvement: A grounded theory study of challenges in utilizing a surgical safety checklist as experienced by nurses in the operating room. BMC Nurs 2012;11:16.
67. Healy JM. How hospital leaders implemented a safe surgery protocol in Australian hospitals. Int J Qual Health Care 2012;24:88-94.
68. Fourcade A, Blache J-L, Grenier C, et al. Barriers to staff adoption of a surgical safety checklist. BMJ Qual Saf 2012;21:191-7.
69. O'Connor P, Reddin C, O'Sullivan M, et al. Surgical checklists: The human factor. Patient Saf Surg 2013;7:14.
70. Papaconstantinou HT, Jo C, Reznik SI, et al. Implementation of a surgical safety checklist: impact on surgical team perspectives. Ochsner J 2012;13:299-309.
71. Kaderli R, Seelandt JC, Umer M, et al. Reasons for the persistence of adverse events in the era of safer surgery-A qualitative approach. Swiss Med Wkly 2013;143:w13882.
72. Aveling EL, McCulloch P, Dixon-Woods M. A qualitative study comparing experiences of the surgical safety checklist in hospitals in high-income and low-income countries. BMJ Open 2013;3:e003039.
73. Bashford T, Reshamwalla S, McAuley J, et al. Implementation of the WHO Surgical Safety Checklist in an Ethiopian Referral Hospital. Patient Saf Surg 2014;8:16.
74. Gagliardi AR, Straus SE, Shojania KG, et al. Multiple interacting factors influence adherence, and outcomes associated with surgical safety checklists: A qualitative study. PLoS ONE 2014;9:e108585.
75. Rönnberg L, Nilsson U. Swedish nurse anesthetists' experiences of the WHO surgical safety checklist. J Perianesthesia Nurs 2014. In press. doi:10.1016/j.jopan.2014.01.011
76. Russ SJ, Sevdalis N, Moorthy K, et al. A qualitative evaluation of the barriers and facilitators toward implementation of the WHO surgical safety checklist across hospitals in England: lessons from the "Surgical Checklist Implementation Project." Ann Surg 2015;261:81-91.
77. Haugen AS, Høyland S, Thomassen O, et al. "It"s a State of Mind': A qualitative study after two years' experience with the World Health Organization's surgical safety checklist. Cogn Tech Work 2015;17:55-62.
78. Lambrechts F, Grieten S, Bouwen R, et al. Process Consultation Revisited: Taking a Relational Practice Perspective. J Appl Behav Sci 2009;45:39-58.
79. Rydenfält C, Ek A, Larsson PA. Safety checklist compliance and a false sense of safety: new directions for research. BMJ Qual Saf 2014;23:183-6.
80. Pierce JL, Kostova T, Dirks KT. Toward a theory of psychological ownership in organizations. Acad Manag Rev 2001;26:298-310.
81. Pierce JL, Jussila I. Collective psychological ownership within the work and organizational context: construct introduction and elaboration. J Organiz Behav 2009;31:810-34.
82. Walton M, Barraclough B. Clinical supervisors: are they the key to making care safer? BMJ Qual Saf 2013;22:609-12.
83. Edmondson AC, Bohmer RM, Pisano GP. Disrupted routines: team learning and new technology implementation in hospitals. Adm Sci Q 2001;46:685-716.
84. Edmondson AC, Dillon JR, Roloff KS. 6 Three perspectives on team learning. Acad Manag Ann 2007;1:269-314.
85. Parmelli E, Flodgren G, Beyer F, et al. The effectiveness of strategies to change organisational culture to improve healthcare performance: A systematic review. Implement Sci 2011;6:33.
86. Chemers M. An integrative theory of leadership. Psychology Press, 1997.
87. Nembhard IM, Edmondson AC. Making it safe: The effects of leader inclusiveness and professional status on psychological safety and improvement efforts in health care teams. J Organiz Behav 2006;27:941-66.
88. Bosk CL, Dixon-Woods M, Goeschel CA, et al. Reality check for checklists. Lancet 2008;374:444-5.
89. Zohar D. Safety climate and beyond: A multi-level multi-climate framework. Saf Sci 2007;46:376-87.
90. Zohar D. Thirty years of safety climate research: reflections and future directions. Accid Anal Prev 2010;42:6-6.
91. Edmondson AC. Framing for learning: lessons in successful technology implementation. Calif Rev 2003;45:34-54.
92. 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.
93. Bohmer AB, Kindermann P, Schwanke U, et al. Long-term effects of a perioperative safety checklist from the viewpoint of personnel. Acta Anaesthesiol Scand 2013;57:150-7.
94. Edmondson AC. Pychological safety and learning behaviour in work teams. Adm Sci Q 1999;44:350-83.