Impact of the Norwegian National Patient Safety Program on implementation of the WHO Surgical Safety Checklist and on perioperative safety culture

Objectives Our primary objective was to study the impact of the Norwegian National Patient Safety Campaign and Program on Surgical Safety Checklist (SSC) implementation and on safety culture. Secondary objective was associations between SSC fidelity and safety culture. We hypothesised that the programme influenced on SSC use and operating theatre personnel’s safety culture perceptions. Setting A longitudinal cross-sectional study was conducted in a large Norwegian tertiary teaching hospital. Participants We invited 1754 operating theatre personnel to participate in the study, of which 920 responded to the surveys at three time points in 2009, 2010 and 2017. Primary and secondary outcome measures Primary outcome was the results of the patient safety culture measured by the culturally adapted Norwegian version of the Hospital Survey on Patient Safety Culture. Our previously published results from 2009/2010 were compared with new data collected in 2017. Secondary outcome was correlation between SSC fidelity and safety culture. Fidelity was electronically recorded. Results Survey response rates were 61% (349/575), 51% (292/569) and 46% (279/610) in 2009, 2010 and 2017, respectively. Eight of the 12 safety culture dimensions significantly improved over time with the largest increase being ‘Hospital managers’ support to patient safety’ from a mean score of 2.82 at baseline in 2009 to 3.15 in 2017 (mean change: 0.33, 95% CI 0.21 to 0.44). Fidelity in use of the SSC averaged 88% (26 741/30 426) in 2017. Perceptions of safety culture dimensions in 2009 and in 2017 correlated significantly though weakly with fidelity (r=0.07–0.21). Conclusion The National Patient Safety Program, fostering engagement from trust boards, hospital managers and frontline operating theatre personnel enabled effective implementation of the SSC. As part of a wider strategic safety initiative, implementation of SSC coincided with an improved safety culture.publishedVersio

Feasibility of implementing a surgical patient safety checklist: prospective cross-sectional evaluation

Background The World Health Organization’s Global Patient Safety Action Plan 2021–2030 call for attention to patient and family involvement to reduce preventable patient harm. Existing evidence indicates that patients’ involvement in their own safety has positive effects on reducing hospitalisation time and readmissions. One intervention reported in the literature is the use of checklists designed for patients’ completion. Studies on such checklists are small scale, but they are linked to reduction in length of hospital stay and readmissions. We have previously developed and validated a two-part surgical patient safety checklist (PASC). This study aims to investigate the feasibility of the PASC usage and implementation prior to its use in a large-scale clinical trial. Methods This is a prospective cross-sectional feasibility study, set up as part of the design of a larger stepped-wedge cluster randomised controlled trial (SW-CRCT). Descriptive statistics were used to investigate patient demographics, reasons for not completing the PASC and percentage of PASC item usage. Qualitative patient interviews were used to identify barriers and drivers for implementation. Interview was analysed through content analysis. Results Out of 428 recruited patients, 50.2% (215/428) used both parts of PASC. A total of 24.1% (103/428) of the patients did not use it at all due to surgical or COVID-19-related cancellations. A total of 19.9% (85/428) did not consent to participate, 5.1% (22/428) lost the checklist and 0.7% (3/428) of the patients died during the study. A total of 86.5% (186/215) patients used ≥ 80% of the checklist items. Barriers and drivers for PASC implementation were grouped into the following categories: Time frame for completing the checklist, patient safety checklist design, impetus to communicate with healthcare professionals and support throughout the surgical pathway. Conclusions Elective surgical patients were willing and able to use PASC. The study further revealed a set of barriers and drivers to the implementation. A large-scale definitive clinical-implementation hybrid trial is being launched to ascertain the clinical effectiveness and scalability of PASC in improving surgical patient safety.publishedVersio

Development and validation of patients' surgical safety checklist

Background Poor uptake and understanding of critical perioperative information represent a major safety risk for surgical patients. Implementing a patient-driven surgical safety checklist might enhance the way critical information is given and increase patient involvement in their own safety throughout the surgical pathway. The aim of this study was to develop and validate a Surgical Patient Safety Checklist (PASC) for use by surgical patients. Method This was a prospective study, involving patient representatives, multidisciplinary healthcare professionals and elective surgical patients to develop and validate PASC using consensus-building techniques in two Norwegian hospitals. A set of items intended for PASC were rated by patients and then submitted to Content Validation Index (CVI) analyses. Items of low CVI went through a Healthcare Failure Mode and Effect Analysis (HFMEA) Hazard Scoring process, as well as a consensus process before they were either kept or discarded. Reliability of patients’ PASC ratings was assessed using Intraclass Correlation Coefficient analysis. Lastly, the face validity of PASC was investigated through focus group interviews with postoperative patients. Results Initial development of PASC resulted in a checklist consisting of two parts, one before (32 items) and one after surgery (26 items). After achieving consensus on the PASC content, 215 surgical patients from six surgical wards rated the items for the CVI analysis on a 1-4 scale and mostly agreed on the content. Five items were removed from the checklist, and six items were redesigned to improve PASCs’ user-friendliness. The total Scale-level index/Average (S-CVI/Ave) before revision was 0.83 and 0.86 for pre- and post-operative PASC items, respectively. Following revision, these increased to 0.86 and 0.93, respectively. The PASC items reliability score was 0.97 (95% confidence interval 0.96 to 0.98). The qualitative assessment identified that patients who used PASC felt more in control of their situation; this was achieved when PASC was given to them at what they felt was the right time and healthcare professionals took part in its usage. Conclusion Multidisciplinary perioperative care staff and surgical patients agreed upon PASC content, the checklist ratings were reliable, and qualitative assessment suggested good face validity. PASC appears to be a usable and valid checklist for elective surgical patients across specialties.publishedVersio

Влияние изменений климата на геоэкологические риски нефтегазовой отрасли в районах вечной мерзлоты

Objective: We hypothesize that high-quality implementation of the World Health Organization's Surgical Safety Checklist (SSC) will lead to improved care processes and subsequently reduction of peri- and postoperative complications. Background: Implementation of the SSC was associated with robust reduction in morbidity and length of in-hospital stay in a stepped wedge cluster randomized controlled trial conducted in 2 Norwegian hospitals. Further investigation of precisely how the SSC improves care processes and subsequently patient outcomes is needed to understand the causal mechanisms of improvement. Methods: Care process metrics are reported from one of our earlier trial hospitals. Primary outcomes were in-hospital complications and care process metrics, e.g., patient warming and antibiotics. Secondary outcome was quality of SSC implementation. Analyses include Pearson's exact χ 2 test and binary logistic regression. Results: A total of 3702 procedures (1398 control vs. 2304 intervention procedures) were analyzed. High-quality SSC implementation (all 3 checklist parts) improved processes and outcomes of care. Use of forced air warming blankets increased from 35.3% to 42.4% (P < 0.001). Antibiotic administration postincision decreased from 12.5% to 9.8%, antibiotic administration preincision increased from 54.5% to 63.1%, and nonadministration of antibiotics decreased from 33.0% to 27.1%. Surgical infections decreased from 7.4% (104/1398) to 3.6% (P < 0.001). Adjusted SSC effect on surgical infections resulted in an odds ratio (OR) of 0.52 (95% confidence interval (CI): 0.38–0.72) for intervention procedures, 0.54 (95% CI: 0.37–0.79) for antibiotics provided before incision, and 0.24 (95% CI: 0.11–0.52) when using forced air warming blankets. Blood transfusion costs were reduced by 40% with the use of the SSC. Conclusions: When implemented well, the SSC improved operating room care processes; subsequently, high-quality SCC implementation and improved care processes led to better patient outcomes

Impact of a surgical safety checklist on safety culture, morbidity, and mortality. A stepped-wedge cluster randomised controlled trial

Introduction: The incidence of in-hospital adverse events is estimated to occur in approximately 1 out of 10 patients. Events happening during surgical procedures contribute up to 60%, and of these, more than half are considered to be preventable. Communication breakdowns have been identified as an important contributor to errors. The introduction of surgical safety checklists that are intended to improve teamwork and communication decreases both morbidity and mortality. It has been hypothesised that improved patient outcomes result from changes in safety culture. Thus, randomised controlled studies are warranted in order to investigate whether the use of checklists are responsible for positive effects on patient outcomes. Aims: 1. In the study reported in Paper 1, we aimed to (1) validate the psychometric properties of the Hospital Survey on Patient Safety Culture (HSOPS) in a surgical environment, and (2) to compare results from its use on the safety culture in healthcare personnel in different countries. 2. In the study reported in Paper 2, we aimed to determine whether use of the World Health Organization (WHO) Surgical Safety Checklist (SSC) positively affects safety culture. We used the HSOPS to assess this. 3. In the study reported in Paper 3, we aimed to determine whether the use of the WHO SSC positively affects patient outcomes, reducing morbidity, mortality, and length of hospital stay. Methods: In the first study, a cross-sectional survey using the HSOPS was conducted in 575 surgical personnel at Haukeland University Hospital in 2009. Surgeons, operating theatre nurses, anaesthetists, nurse anaesthetists, and ancillary personnel were included. We used explorative factor analysis to examine the applicability and the internal consistency of the HSOPS factor structure in operating theatre settings. This survey constituted the baseline measure in the second study. In the second study, the WHO SSC was introduced after the baseline survey was completed, along with an educational programme that provided the rationale for why and how the checklist was to be used. The implementation was carried out with a stepped-wedge cluster, randomised controlled design and was conducted in three surgical specialties (orthopaedic, cardiothoracic, and neurosurgery) at Haukeland University Hospital; the order of implementation for the three specialties was randomised. The control group comprised surgical personnel from ear, nose, and throat; maxillofacial; plastic; endocrine; urological; gastrointestinal; obstetric; and gynaecological surgical specialities. In this study, the controls did not receive the WHO SSC intervention during the study period. A total of 349 participants responded at baseline assessment, and 292 responded at post-intervention assessment. The primary outcome measure was the values of the twelve safety culture factors of the HSOPS, and the secondary outcome measure was the degree of WHO SSC compliance. In the third study, the WHO SSC was implemented using a stepped-wedge cluster randomised controlled design in five surgical specialties. Three (orthopaedic, cardiothoracic, and neurosurgery) were from Haukeland University Hospital and two (urology and general surgery) were from Førde Central Hospital, with a total of 5,295 surgical procedures included. The intervention was randomised and conducted until all five specialties had received it. We examined whether using the WHO SSC affects in-hospital complications, as measured by ICD-10 codes, length of stay, and postsurgical mortality (up to 30 days). Results: In the first study, the HSOPS was determined to be valid for measuring safety culture in an operating theatre setting, with internal consistency and Cronbach’s alpha values ranging from 0.59 to 0.85. A twelve-factor structure of the survey instrument was supported.In the second study, the WHO SSC intervention had a significant impact on two safety culture factors—‘frequency of events (near misses) reported’ and ‘adequate staffing’—in the intervention group, with regression coefficients of -0.25 (95% CI, - 0.47 to -0.07) and 0.21 (95% CI, 0.07 to 0.35), respectively. Between baseline and post-intervention assessments, there was a significant improvement in the factors ‘hospital management promoting safety’ and ‘handoffs and transitions’, with regression coefficients of 0.12 (95% CI, 0.04 to 0.20) and 0.08 (95% CI, 0.01 to 0.14), respectively. In the third study, we observed a significant decrease in complications from 19.9% to 11.5% in 2,212 surgical procedures before and 2,263 after implementation of the WHO SSC (P<0.001). The absolute risk reduction (ARR) was 8.4 (95% CI, 6.3 to 10.5). Adjusted for possible confounding factors, the WHO SSC effect on complications remained significant, with an odds ratio of 1.95 (95% CI, 1.59 to 2.40). The checklist prevented one or more complications when used in twelve surgical procedures. Mean length of stay decreased by 0.8 days (95% CI, 0.11 to 1.43). Although in-hospital mortality decreased significantly from 1.9% to 0.2% in the central community hospital, the overall reduction of mortality (from 1.6% to 1.0%) across hospitals was not statistically significant. Conclusions: The HSOPS was determined to be valid for use in this specific clinical setting. The WHO SSC intervention had a rather limited effect on the overall safety culture, but significantly changed perceptions of surgical professionals in the intervention group on two factors, ‘frequency of events reported’ and ‘adequate staffing’. The steppedwedge cluster randomised implementation of the WHO SSC was associated with robust reduction in morbidity and length of stay, and some reduction in mortality

Adjusting team involvement: a grounded theory study of challenges in utilizing a surgical safety checklist as experienced by nurses in the operating room

Background: Even though the use of perioperative checklists have resulted in significant reduction in postoperative mortality and morbidity, as well as improvements of important information communication, the utilization of checklists seems to vary, and perceived barriers are likely to influence compliance. In this grounded theory study we aimed to explore the challenges and strategies of performing the WHO’s Safe Surgical Checklist as experienced by the nurses appointed as checklist coordinators. Methods: Grounded theory was used in gathering and analyzing data from observations of the checklist used in the operating room, in conjunction with single and focus group interviews. A purposeful sample of 14 nurse-anesthetists and operating room nurses as surgical team members in a tertiary teaching hospital participated in the study. Results: The nurses’ main concern regarding checklist utilization was identified as “how to obtain professional and social acceptance within the team”. The emergent grounded theory of “adjusting team involvement” consisted of three strategies; distancing, moderating and engaging team involvement. The use of these strategies explains how they resolved their challenges. Each strategy had corresponding conditions and consequences, determining checklist compliance, and how the checklist was used. Conclusion: Even though nurses seem to have a loyal attitude towards the WHO’s checklist regarding their task work, they adjusted their surgical team involvement according to practical, social and professional conditions in their work environment. This might have resulted in the incomplete use of the checklist and therefore a low compliance rate. Findings also emphasized the importance of: a) management support when implementing WHO’s Safe Surgical Checklist, and b) interprofessional education approach to local adaptation of the checklists use

A survey of surgical team members' perceptions of near misses and attitudes towards Time Out protocols

Background: Medical errors are inherently of concern in modern health care. Although surgical errors as incorrect surgery (e.g., wrong patient, wrong site, or wrong procedure) are infrequent, they are devastating events to experience. To gain insight about incidents that could lead to incorrect surgery, we surveyed how surgical team members perceive near misses and their attitudes towards the use of Time Out protocols in the operating room. We hypothesised that perceptions of near-miss experiences and attitudes towards Time Out protocols vary widely among surgical team members. Methods: This cross-sectional study (N = 427) included surgeons, anaesthetists, nurse anaesthetists, and operating room nurses. The questionnaire consisted of 14 items, 11 of which had dichotomous responses (0 = no; 1 = yes) and 3 of which had responses on an ordinal scale (never = 0; sometimes = 1; often = 2; always = 3). Items reflected team members’ experience of near misses or mistakes; their strategies for verifying the correct patient, site, and procedure; questions about whether they believed that these mistakes could be avoided using the Time Out protocol; and how they would accept the implementation of the protocol in the operating room. Results: In the operating room, 38% of respondents had experienced uncertainty of patient identity, 81% had experienced uncertainty of the surgical site or side, and 60% had prepared for the wrong procedure. Sixty-three per cent agreed that verifying the correct patient, site, and procedure should be a team responsibility. Thus, only nurse anaesthetists routinely performed identity checks prior to surgery (P ≤ 0.001). Of the surgical team members, 91% supported implementation of a Time Out protocol in their operating rooms. Conclusion: The majority of our surgical personnel experienced near misses with regard to correct patient identity, surgical site, or procedure. Routines for ensuring the correct patient, site, and surgical procedure must involve all surgical team members. We find that the near-miss experiences are a wake-up call for systematic risk reducing efforts and the use of checklists in surgery

How does the WHO Surgical Safety Checklist fit with existing perioperative risk management strategies? An ethnographic study across surgical specialties

Background The World Health Organization (WHO) Surgical Safety Checklist (SSC) has demonstrated beneficial impacts on a range of patient- and team outcomes, though variation in SSC implementation and staffʼs perception of it remain challenging. Precisely how frontline personnel integrate the SSC with pre-existing perioperative clinical risk management remains underexplored – yet likely an impactful factor on how SSC is being used and its potential to improve clinical safety. This study aimed to explore how members of the multidisciplinary perioperative team integrate the SSC within their risk management strategies. Methods An ethnographic case study including observations (40 h) in operating theatres and in-depth interviews of 17 perioperative team members was carried out at two hospitals in 2016. Data were analysed using content analysis. Results We identified three themes reflecting the integration of the SSC in daily surgical practice: 1) Perceived usefullness; implying an intuitive advantage assessment of the SSCʼs practical utility in relation to relevant work; 2) Modification of implementation; reflecting performance variability of SSC on confirmation of items due to precence of team members; barriers of performance; and definition of SSC as performance indicator, and 3) Communication outside of the checklist; including formal- and informal micro-team formations where detailed, specific risk communication unfolded. Conclusion When the SSC is not integrated within existing risk management strategies, but perceived as an “add on”, its fidelity is compromised, hence limiting its potential clinical effectiveness. Implementation strategies for the SSC should thus integrate it as a risk-management tool and include it as part of risk-management education and training. This can improve team learning around risk comunication, foster mutual understanding of safety perspectives and enhance SSC implementation.publishedVersio

Elderly patients’ (≥65 years) experiences associated with discharge; Development, validity and reliability of the Discharge Care Experiences Survey

Background A review of the literature reveals a lack of validated instruments that particularly measure quality in the hospital discharge process. This study aims to develop and validate a survey instrument feasible for measuring quality (≥65 years) related to the discharge process based on elderly patients’ experiences. Methods Construction of the Discharge Care Patient Experience Survey (DICARES) was based on 16 items identified by literature reviews. Intraclass correlation for test–retest was applied to assess consistency of the survey. Explorative factors analysis was applied to identify and validate the factor structures of the DICARES. Cronbach’s α was used to assess internal reliability. To evaluate the external validity of the final DICARES questionnaire the patients’ scores were correlated with scores obtained from the three other questionnaires; the Nordic Patient Experiences Questionnaire, the 12-Item Short-Form Health Survey and Subjective Health Complaints. The DICARES association with readmissions was examined. Results A total of 270 patients responded (64.4%). The mean age of participants was 77.1 years and 57.8% were men. The exploratory factor analysis resulted in a 10-item instrument consisting of three factors explaining 63.5% of the total variance. The Cronbach’s α were satisfactory (≥70). Overall intraclass correlation was 0.76. A moderate Spearman correlation (rho = 0.54, p <0.01) was found between the total mean DICARES score and total mean score of the Nordic Patient Experiences Questionnaire. The total mean DICARES score was inversely associated with the quality indicator based on readmissions (OR 0.62, CI 95: 0.41–0.95, p = 0.028) Conclusion We have developed a 10-item questionnaire consisting of three factors which may be a feasible instrument for measuring quality of the discharge process in elderly patients. Further testing in a wider population should be carried out before implementation in health care settings.publishedVersio