Jennifer Blakelidge talks about the success and barriers following the creation of the WHO standardised Surgical Safety Checklist (SSC)
Introduction
The World Alliance for Patient Safety [1] identified surgery as the most complex intervention in healthcare, stating that well known safety principles are inconsistently applied; this motivated the creation of the WHO standardised Surgical Safety Checklist (SSC).
Studies have consistently demonstrated reductions in mortality and morbidity due to the use of surgical checklists. Despite its success, issues have arisen with compliance, engagement and the continuation of serious preventable surgical incidents known as ‘never events’ [2, 3].
The WHO checklist was developed from the aviation industry in which checklists have been in use following a Boeing 299 crash in 1935 [4].The National Patient Safety Agency [5] introduced the ‘five steps to safer surgery’ which added two further sections to be used alongside the SSC to further reduce complications. Sixty-six per cent of health related adverse effects within developed countries occur during surgery with 4 per cent leading to death [6].
An international comprehensive study found a decrease in mortality rates from 1.5 per cent to 0.8 per cent after the implementation of the SSC [7]. Many authors agree that implementation of the checklist significantly reduces postoperative morbidity and mortality [7, 8, 9]. SSC compliance varies greatly from 8.8 per cent to 87.4 per cent in previous observational studies [10-13].
The WHO checklist is 10 years old and some have suggested that it lacks clarity [14] and requires modification as it is not effective as it should be [15]. Additional tools and checks have been created to use alongside the SSC, such as ’10,000 feet’ [16] and ‘Sterile cockpit’ [17] to improve patient outcomes. The SSC is designed to be used worldwide and its simple checklist style approach to potentially complex issues could necessitate from the need for it to be accessible to both developing and developed countries [18].
The public expect minimised risk in healthcare [19]. Seventy-five per cent of people want the SSC used in their operations, with 66 per cent believing it reduces error [20]. In practice there is minimal explanation given to patients for why the checks are being conducted. This can lead to frustration from patients [14]. Prentice [21] contends that checklists move knowledge of complex procedures into a tick box form, which could lead to lack of engagement from staff. O’Brien et al., indicate that despite the checklist’s national introduction in 2009, it is still fraught with challenges during use [8]. The NHS England Patient Safety Association[24] notes that 362 perioperative incidents known as ‘never events’ occurred between April – December 2017, and of these 297 were related to surgery. This implies that the SSC is not working as effectively as intended, to reduce these poor outcomes. Locally, when ‘never events’ have occurred, this has led to changes to the SSC along with searching the aviation industry for additional improvements which are transferrable to theatre.
Several key issues with meaningful use of the SSC were identified including non-technical skills, the checklist itself, additional tools and hierarchy of theatre staff.
Non-Technical skills
Non-technical skills in perioperative practice include communication, teamwork, leadership, decision-making and situation awareness [25]. Checklist literature highlights communication as the most important factor in successful SSC implementation. Although some have shown a low adherence to checklists resulting in surgical delays [22] and hindrance to workflow [26], there is evidence to suggest that the surgical checklists are associated with improved communication, detection of safety issues and decreased complications for patients [14]. Benham et al, documented 24 preventable sources of delay being picked up by the use of SSC [27].
Prentice [21] highlights that the biggest threats to complex systems are the result of human rather than technical failures, adding that checklists may risk turning surgery into a system, with individual differences being overlooked. Kilduff et al., [10] adds that reliance on checklists may create non-engagement with safety protocols and cause a culture of reliance on interventions rather than understanding of how human factors influence outcomes. An awareness of human error as a factor in poor surgical outcomes has be