Dataset Information

Implementation of the WHO Surgical Safety Checklist in an Ethiopian Referral Hospital.

ABSTRACT:

Background

The WHO Surgical Safety Checklist has a growing evidence base to support its role in improving perioperative safety, although its impact is likely to be directly related to the effectiveness of its implementation. There remains a paucity of documented experience from low-resource settings on Checklist implementation approaches. We report an implementation strategy in a public referral hospital in Addis Ababa, Ethiopia, based on consultation, local leadership, formal introduction, and supported supervision with subsequent audit and feedback.

Methods

Planning, implementation and assessment took place from December 2011 to December 2012. The planning phase, from December 2011 until April 2012, involved a multidisciplinary consultative approach using local leaders, volunteer clinicians, and staff from non-governmental organisations, to draw up a locally agreed and appropriate Checklist. Implementation in April 2012 involved formal teaching and discussion, simulation sessions and role play, with supportive supervision following implementation. Assessment was performed using completed Checklist analysis and staff satisfaction questionnaires at one month and further Checklist analysis combined with semi-structured interviews in December 2012.

Results and discussion

Checklist compliance rates were 83% for general anaesthetics at one month after implementation, with an overall compliance rate of 65% at eight months. There was a decrease in Checklist compliance over the period of the study to less than 20% by the end of the study period. The 'Sign out' section was reported as being the most difficult section of the Checklist to complete, and was missed completely in 21% of cases. The most commonly missed single item was the team introduction at the start of each case. However, we report high staff satisfaction with the Checklist and enthusiasm for its continued use.

Conclusion

We report a detailed implementation strategy for introducing the WHO Surgical Safety Checklist to a low-resource setting. We show that this approach can lead to high completion rates and high staff satisfaction, albeit with a drop in completion rates over time. We argue that maximal benefit of the Surgical Safety Checklist is likely to be when it engenders a conversation around patient safety within a department, and when there is local ownership of this process.

SUBMITTER: Bashford T

PROVIDER: S-EPMC4022152 | biostudies-literature | 2014

REPOSITORIES: biostudies-literature

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Publications

Implementation of the WHO Surgical Safety Checklist in an Ethiopian Referral Hospital.

Bashford Tom T Reshamwalla Sophie S McAuley Jacqueline J Allen Nikole H NH McNatt Zahirah Z Gebremedhen Yohannes D YD

Patient safety in surgery 20140328

<h4>Background</h4>The WHO Surgical Safety Checklist has a growing evidence base to support its role in improving perioperative safety, although its impact is likely to be directly related to the effectiveness of its implementation. There remains a paucity of documented experience from low-resource settings on Checklist implementation approaches. We report an implementation strategy in a public referral hospital in Addis Ababa, Ethiopia, based on consultation, local leadership, formal introducti ...[more]

PMID: 24678854

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Project description:Ethiopia has one of the world's poorest neonatal mortality rates (1). As a British paediatrician working for one year, the main aim was to improve neonatal care in a referral hospital's neonatal unit. An initial project looking at all admissions to the unit over the month of October 2012, revealed the death rate within the unit was 21% of all admissions. Of the 55 admissions only 43 (75%) had a temperature recorded at admission. 29 (67%) of these were hypothermic, and of these 29 initially hypothermic babies, 19 (65%) remained hypothermic or did not have another temperature documented during their stay. Only 33 (56%) had a heart rate and respiratory rate recorded on admission and only 11 (19%) had any further vital signs recorded during their stay. 19 of the admitted infants had a diagnosis of low birth weight and 10 (53%) of these either died or left against medical advice. With this information regular basic neonatal care teaching sessions for doctors and nursing staff were initiated. Vital signs charts were introduced and unit specific protocols were written. Continuous Positive Airway Pressure (CPAP) was trialled and found to be effective, and CPAP training was given to all nurses and doctors on the unit. A room was set aside to be used solely as Kangaroo Mother Care (KMC). The nurses were taken to a very effective neonatal unit as an 'experience sharing' trip to help with motivation and a grant was also obtained for basic equipment. After 6 months the project was repeated for all the admissions during February 2013. The death rate had progressively fallen and was 10% in February. 54 patients (98%) had a temperature taken on admission and of these, 27 (49%) were hypothermic. 25 (93%) of these hypothermic infants had subsequent temperatures documented which were normal. 54 (98%) had heart rate and respiratory rate recorded on admission and 50 (90%) had them recorded at least daily during their stay. Of the 22 babies with low birth weight (40%), only 4 (18%) died/left against medical advice. 4 received CPAP and 6 were treated with KMC.

Project description:The 2009 World Health Organisation (WHO) surgical safety checklist significantly reduces surgical mortality and morbidity (up to 47%). Yet in 2016, only 25% of East African anesthetists regularly use the checklist. Nationwide implementation of the checklist is reported in high-income countries, but in low- and middle-income countries (LMICs) reports of successful implementations are sparse, limited to single institutions and require intensive support. Since checklist use leads to the biggest improvements in outcomes in LMICs, methods of wide-scale implementation are needed. We hypothesized that, using a three-day course, successful wide-scale implementation of the checklist could be achieved, as measured by at least 50% compliance with six basic safety processes at three to four months. We also aimed to determine predictors for checklist utilization.Using a blended educational implementation strategy based on prior pilot studies we designed a three-day dynamic educational course to facilitate widespread implementation of the WHO checklist. The course utilized lectures, film, small group breakouts, participant feedback and simulation to teach the knowledge, skills and behavior changes needed to implement the checklist. In collaboration with the Ministry of Health and local hospital leadership, the course was delivered to 427 multi-disciplinary staff at 21 hospitals located in 19 of 22 regions of Madagascar between September 2015 and March 2016. We evaluated implementation at three to four months using questionnaires (with a 5-point Likert scale) and focus groups. Multivariate linear regression was used to test predictors of checklist utilization.At three to four months, 65% of respondents reported always using the checklist, with another 13% using it in part. Participant's years in practice, hospital size, or surgical volume did not predict checklist use. Checklist use was associated with counting instruments (p< 0.05), but not with verifying: patient identity, difficult intubation risk, risk of blood loss, prophylactic antibiotic administration, or counting needles and sponges.Use of a multi-disciplinary three-day course for checklist implementation resulted in 78% of participants using the checklist, at three months; and an increase in counting surgical instruments. Successful checklist implementation was not predicted by participant length of medical service, hospital size or surgical volume. If reproducible in other countries, widespread implementation in LMICs becomes a realistic possibility.

Project description:Introduction:The use of a surgical safety checklist is recommended by the World Health Organization and is associated with advantages: improved communication and reduced complications and mortality. Adapting checklists to the environment in which they are used improves their efficiency, but their implementation can be challenging. The aim of this study was to develop and implement a perianesthetic safety checklist for a small animal hospital. Materials and methods:A panel of eight anesthesia diplomates and seven residents and doctoral students were gathered. The Delphi method was used to generate a checklist. The checklist was presented individually to each user by the primary investigator and introduced into the clinical routine over a 5-week period. An interdisciplinary meeting was then held, and the checklist was modified further. Six months after introduction, the use of the checklist was directly observed during 69 anesthetic cases and a survey was sent to the users. A second implementation was organized after formally presenting the checklist to the staff, designating the anesthesia clinical lead as the person responsible for printing and controlling use of the checklist. A second evaluation was performed 3?months later (64 anesthetic cases). Results:Using the Delphi process led to the creation of a checklist consisting of three parts: "sign in" (before induction of anesthesia), "time out" (before the beginning of the procedure), "sign out" (at the end of the procedure). At the first assessment, the checklist was printed and used in 32% of cases and not printed in 41% of cases. Response rate of the survey was fair (19/32 surveys): 14/19 users thought the checklist contributed to improving communication; 15/19 reported improved safety and better management of the animals; 9/19 users avoided mistakes (77% would have omitted the administration of antimicrobial prophylaxis); 10/19 thought it was time consuming. At the second assessment, the checklist was used in 45% of cases (printed but not used in 55%). The use of the sign-out section of the checklist was significantly improved. Conclusion and clinical relevance:This study illustrates an innovative use of the Delphi method to create a safety checklist. Challenges associated with implementation are reported.

Project description:The surgical Safety Checklist (SSC) was introduced in 2008 to improve teamwork and reduce the mortality and morbidity associated with surgery. Although mandated in many health care institutions around the world, challenges in implementation of the SSC continue. To use Normalisation Process Theory (NPT) to help understand how/why implementation of a complex intervention coined Pass The Baton (PTB) could help explain what facets of the Surgical Safety Checklist use led to its' integration in practice, while others were not.A longitudinal multi-method study using survey and interviews was undertaken. Implementation of PTB involved; change champions, audit and feedback, education and prompts. Following implementation, surgical teams were surveyed using the NOrmalization MeAsure Development (NoMAD) and subsequently interviewed to explore the impact of PTB on their use of the checklist at 6 and 12 months respectively. Respondents' self-reported perceptions of implementation of PTB was explained using the four NPT constructs; coherence, cognitive participation, collective action, and reflexive monitoring. Survey data were analysed using descriptive statistics. Interview data were coded inductively and content analysed using a framework derived from NPT.The NoMAD survey response rate was 59/150 (39.3%). Many (45/59, 77.6%) survey respondents saw the value in PTB, while 50/59 (86.2%) would continue to use it; 45/59 (77.6%) believed that PTB could easily be integrated into existing workflows, and 48/59 (82.8%) thought that feedback could improve PTB in the future. A total of 8 interviews were completed with 26 surgical team members. Nurses and physicians held mixed views towards coherence while buy-in and participation relied on individuals' investment in the implementation process and the ability to modify PTB. Participants generally recognised the benefit and value of using PTB in the ongoing implementation the checklist.Workarounds and flexible co-construction in implementation designed to improve team communications in surgery may facilitate their normalisation in practice.

Project description:BackgroundSurgical safety has advanced rapidly with evidence of improved patient outcomes through structural and process interventions. However, knowledge of how to apply these interventions successfully and sustainably at scale is often lacking. The 2019 Global Ministerial Patient Safety Summit called for a focus on implementation strategies to maintain momentum in patient safety improvements, especially in low- and middle-income settings. This study uses an implementation framework, knowledge to action, to examine a model of nationwide World Health Organization (WHO) Surgical Safety Checklist implementation in Cameroon. Cameroon is a lower-middle-income country, and based on data from high- and low-income countries, we hypothesized that more than 50% of participants would be using the checklist (penetration) in the correct manner (fidelity) 4 months postintervention.MethodsA collaboration of 3 stakeholders (Ministry of Health, academic institution, and nongovernmental organization) used a prospective observational design. Based on knowledge to action, there were 3 phases to the study implementation: problem identification (lack of routine checklist use in Cameroonian hospitals), multifaceted implementation strategy (3-day multidisciplinary training course, coaching, facilitated leadership engagement, and support networks), and outcome evaluation 4 months postintervention. Validated implementation outcomes were assessed. Primary outcomes were checklist use (penetration) and fidelity; secondary outcomes were perioperative teams' reactions, learning and behavior change; and tertiary outcomes were perioperative teams' acceptability of the checklist.ResultsThree hundred and fifty-one operating room staff members from 25 hospitals received training. Median time to evaluation was 4.5 months (interquartile range [IQR]: 4.5-5.5, range 3-7); checklist use (penetration) increased from 20% (95% confidence interval [CI], 16-25) to 56% (95% CI, 49-63); fidelity for adherence to 6 basic safety processes was high: verification of patient identification was 91% (95% CI, 87-95); risk assessment for difficult intubation was 79% (95% CI, 73-85): risk assessment for blood loss was 88% (95% CI, 83-93) use of pulse oximetry was 93% (95% CI, 90-97); antibiotic administration was 95% (95% CI, 91-98); surgical counting was 89% (95% CI, 84-93); and fidelity for nontechnical skills measured by the WHO Behaviorally Anchored Rating Scale was 4.5 of 7 (95% CI, 3.5-5.4). Median scores for all secondary outcomes were 10/10, and 7 acceptability measures were consistently more than 70%.ConclusionsThis study shows that a multifaceted implementation strategy is associated with successful checklist implementation in a lower-middle-income country such as Cameroon, and suggests that a theoretical framework can be used to practically drive nationwide scale-up of checklist use.

Project description:AIMS AND OBJECTIVES:To explore the extent to which a checklist designed to support patient safety in hospital Emergency Departments was recognised and used by staff. BACKGROUND:Patient crowding in UK Emergency Departments makes it difficult for staff to monitor all patients for signs of clinical deterioration. An Emergency Department Safety Checklist was developed at a UK hospital to ensure patients are regularly monitored. It was subsequently implemented in six hospitals and recommended for use across the National Health Service in England. METHODS:This was a qualitative study in two UK hospital Emergency Departments. Data collection consisted of sixty-six hours of nonparticipant observation and interviews with twenty-six staff. Observations were sampled across different days and times. Interviews sampled a range of staff. Data were analysed thematically. The study was undertaken in accordance with COREQ guidelines. RESULTS:Staff described the Emergency Department Safety Checklist as a useful prompt and reminder for monitoring patients' vital signs and other aspects of care. It was also reported as effective in communicating patient care status to other staff. However, completing the checklist was also described as a task which could be overlooked during busy periods. During implementation, the checklist was promoted to staff in ways that obscured its core function of maintaining patient safety. CONCLUSIONS:The Emergency Department Safety Checklist can support staff in maintaining patient safety. However, it was not fully recognised by staff as a core component of everyday clinical practice. RELEVANCE TO CLINICAL PRACTICE:The Emergency Department Safety Checklist is a response to an overcrowded environment. To realise the potential of the checklist, emergency departments should take the following steps during implementation: (a) focus on the core function of clinical safety, (b) fully integrate the checklist into the existing workflow and (c) employ a departmental team-based approach to implementation and training.

Dataset Information

Implementation of the WHO Surgical Safety Checklist in an Ethiopian Referral Hospital.

Background

Methods

Results and discussion

Conclusion

Publications

Implementation of the WHO Surgical Safety Checklist in an Ethiopian Referral Hospital.

Similar Datasets

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