Archive July 2017 XVIII, No. 7

Safety: What Good Are Surgical Safety Checklists?

They're effective only if your team uses them — and uses them properly.

Vanessa Lyons, PhD, RN, CNOR

surgical safety checklist CONVERSATION STARTER A surgical safety checklist can be a great tool for improving patient safety, but it's not worth the paper it's printed on unless you use it properly.

Pre-surgical checklists are only as effective as the team using them. To reap the safety benefits, you've got to use your checklist right. Otherwise, it's just one more burdensome task for your surgical team to complete. Follow these 5 tips to ensure your team capitalizes on the tool designed to prevent the communication breakdowns that contribute to most preventable adverse events in surgery.

1Form active leadership. Rely on team facilitators to implement checklists and conduct ongoing quality improvement programs designed to enhance the tool based on your staff's specific needs. Recruit surgeons and anesthesiologists in order to support use of the checklist and break down the hierarchy in the OR. The checklist is designed to improve multidisciplinary communication, which should start in the planning phase. During that time, staff facilitators can help colleagues understand that use of a checklist alone won't ensure patient safety and that the tool is not a checkbox activity completed mindlessly — it's essential that you verify each item as a team.

2Train and discuss. It has been reported that some surgical professionals view checklist implementation as the responsibility of individual surgeons or nurses. That's why it's important to involve the entire team, together, when you teach about the proper use of checklists. Interdisciplinary training encourages the development of mutual respect and collaboration that are required for successful checklist use. It also lets team members practice communicating with their colleagues and address their concerns in an encouraging environment. Training should include education on why the surgical safety checklist was originally developed, evidence that supports its use and the specific benefits it provides to patient safety. Simulate the checklist's use during various clinical scenarios. Have staff discuss how the checklist can be optimized during each drill and ask them to suggest scenarios based on their real-world experiences.

3Customize the design. Make sure the checklist contents and layout meet the specific needs of your facility. It should be based on feedback from your surgical team and the types of procedures you host. Involving staff in the design of the checklist increases the likelihood that they'll use the tool in a meaningful way. Design the checklist based on your current safety protocols instead of ideal practices, because aligning the tool with how your staff actually works increases the likelihood that they'll use it properly. To improve compliance, the checklist should be visible to the entire surgical team, not read off a piece of paper by a single staff member. Incorporating the checklist into electronic medical records can prompt and guide the surgical team through the process and reduce their reliance on rote memory.

4Implement quality improvement. Documentation audits may result in a false sense of security and accuracy of checklist use due to inflated reported completion rates, so use observational audits to measure true compliance (a "secret shopper" approach is one effective method to complete the observations). Update staff on the results of the observational audits and current patient safety statistics, so they're aware of the checklist's real impact on case outcomes. Share specific examples of how the checklist rundown averted potential problems to show its value in your specific clinical setting.

UNDERLYING ISSUES
Reasons for Checklist Pushback

checklist CULTURE OF ARROGANCE Those who resist using a safety checklist might complain about the length of the checklist or argue that everyone is highly trained and doesn't need a checklist to aid them in their work.

Understanding why your staff refuses to use surgical safety checklists will help you address their concerns and increase compliance. Check out these common reasons for the lack of widespread use of checklists and zero in on correcting the ones that you've seen in your facility.

Staff resistance. This is the No. 1 barrier to overcome. Your staff might not understand why the checklist was developed and, because it appears to be a basic tool, might incorrectly assume that little training is needed to master its use. Surgical team members who don't buy into the training that's needed to optimize the checklist will be unfamiliar with how to execute it properly and consistently.

Lack of buy-in. Staff members who aren't involved in planning for the implementation of the checklist won't have a sense of ownership in ensuring a successful rollout. Without staff buy-in, team members may use the checklist as a simple checkbox task, instead of as a useful communication guide.

Redundancy. Staff will likely hesitate to use checklists that require nurses and anesthesia providers to verify the same thing, such as patients' medication allergies. This redundancy, intended as a mechanism to identify potential errors at multiple points before they occur, looks like extra work to staff members, who might resort to workarounds and shortcuts.

Social structure. The OR has historically been a hierarchical environment in which the surgeon is perceived to be the captain of the ship. Surgeon resistance to checklists therefore results in staff members also dismissing the process.

— Vanessa Lyons, PhD, RN, CNOR

5Institute consequences for noncompliance. Once you've identified the barriers to the checklist process (see "Reasons for Checklist Pushback"), provide non-punitive remediation the first time a staff member fails to follow proper checklist protocols. If compliance continues to be an issue, your facility's policy should guide the disciplinary process. Regardless of your policy, consequences for noncompliance must be planned and clearly communicated to staff before checklist implementation. OSM

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