Theatre team learns to use checklist to make surgery safer: introduction of a surgical safety checklist can significantly reduce surgical morbidity and mortality, research has shown. Mark Bittle explains how this initiative was introduced into operating theatres in the Auckland hospital where he works.
Subject: Health care teams (Management)
Surgery (Management)
Surgery (Standards)
Patients (Care and treatment)
Patients (Standards)
Author: Bittle, Mark
Pub Date: 08/01/2011
Publication: Name: Kai Tiaki: Nursing New Zealand Publisher: New Zealand Nurses' Organisation Audience: Trade Format: Magazine/Journal Subject: Health; Health care industry Copyright: COPYRIGHT 2011 New Zealand Nurses' Organisation ISSN: 1173-2032
Issue: Date: August, 2011 Source Volume: 17 Source Issue: 7
Topic: Event Code: 200 Management dynamics; 350 Product standards, safety, & recalls Computer Subject: Company business management
Product: Product Code: 8000410 Surgical Procedures NAICS Code: 62 Health Care and Social Assistance
Geographic: Geographic Scope: New Zealand Geographic Code: 8NEWZ New Zealand
Accession Number: 266344842
Full Text: I am senior registered nurse (RN) working the operating theatres at a large hospital in New Zealand. The quality service improvement team proposed a plan for the introduction of the Surgical Safety Checklist to our operating theatres. This initiative is part of the World Health Organisation (WHO) "safe surgery saves lives" campaign to improve the safety of patients in the operating theatre by ensuring there is adherence to proven standards of care.

In 2008, WHO published a series of recommended guidelines for surgical health professionals to adopt to ensure safe practice. (1) These guidelines involve all health professionals in the operating room multi-disciplinary team anaesthetist, anaesthetic technician, surgeons, nurses and ancillary staff.

The 2008 WHO Surgical Safety Checklist has three stages: Sign In, Time Out and Sign Out. At each stage, oral confirmation must take place before the team continues to the next step. (1)

Sign In is done preoperatively and must be completed by at least one anaesthetic health professional and an RN, prior to any anaesthetic intervention. Among the oral confirmations, the patient must be identified, then this confirmed by the patient, consent must be apparent and the site of surgery must be marked. If the patient has known drug allergies, the team must be informed. The anaesthetist must assess the patient prior to anaesthesia and if there is any possibility of blood loss exceeding 500ml, fluids and bloods must be available prior to starting anaesthesia.

The second stage, Time Out, starts once the patient is in the theatre and on the operating table. It is led by the surgeon, and takes place before surgical incision. Team members introduce themselves by name and role, the patient is identified again, the procedure confirmed and the surgical site again confirmed. Any critical events that may occur during surgery are discussed, so if one occurs, all are aware and respond without undue delay. Confirmation is also given that the patient is safely placed on the operating table with deep vein thrombosis prophylaxis in place. The nurses confirm all required instruments are available and sterile, while the anaesthetist confirms prophylactic antibiotics have been administered within the last 60 minutes.

The third and final stage is Sign Out. When the operation is complete and before the patient leaves the operating room, an RN verbally confirms the procedure, and that instruments, sharps and swab counts are correct, ensures any specimens have the patient's name on the container and that the specimen is labelled correctly. The RN also needs to let appropriate people know if there are any problems with the equipment. Finally, when the patient is handed over to the care of the recovery room nurse, the anaesthetist, surgeon and RN verbally handover a complete breakdown of the care of the patient during their surgical procedure.

Team of coaches allocated

The Surgical Safety Checklist concept was introduced to theatres in my hospital in May 2010. A team of "coaches" from the hospital's quality division were allocated to our theatres to support staff with the introduction. The checklist was to be introduced gradually, starting with the plastics speciality, followed by orthopaedics and general surgery.

Although the nursing team had been introduced to the new concepts in the checklist in staff meetings and via the nursing communication book, the day the checklist started in theatre was one of mixed feelings and emotions among members of the multi-disciplinary team. Apprehension and misunderstanding about the need for change was apparent, as many of the staff showed quite a bit of negativity towards the concepts. Some believed the checklist would be time-consuming, causing delays for the start of surgery. The introduction of the checklist was seen as challenging in this emotionally charged environment.

Before the introduction of the checklist, team meetings were arranged to plan a support framework for a smooth transition to this change in practice. These meetings included representatives from the hospital's quality division, the theatre manager, theatre co-ordinator, the plastics associate clinical nurse manager, the head of department for plastic surgery and a number of his senior registrars. The plan for implementing the checklist using the team of "coaches" was discussed, together with any potential issues that might occur. The format of the checklist was altered to meet the needs and requirements of our hospital. However, the key concepts of the WHO checklist remained intact.

It was agreed at the meetings that the checklist and the new checklist procedure would be re-assessed after one week and then three weeks. Any necessary changes or any problems identified could be addressed immediately.

Feedback from all members of the operating theatre team was important to ensure issues were addressed appropriately and to enable the introduction to succeed.

The involvement of the coaches was pivotal they provided support by talking through what was going on, taught us strategies to manage situations, and instilled a more positive attitude by affirming the benefits of the checklist.

The head of department for plastic surgery took responsibility for getting his surgeons on board to be leaders/champions in the operating theatre. The eagerness of the plastic surgeons was apparent and helped make the transition easier for the first phase of the introduction, although other team members were less enthusiastic.

Chocolate bars were given out as an incentive to staff to participate and to successfully complete each part of the checklist, but this did not always encourage enthusiasm. However, those resisting the change eventually shifted their perception once they realised the benefits, and are now complying.

Understanding the need to change practice in the clinical setting is about ensuring patients are entering a safe environment of care. Before the introduction of the Surgical Safety Checklist, the team would conduct a basic Time Out that covered the minimum of details and was done before knife to skin commenced. There was little engagement with the patient, no introduction of team members, and when compared with the new checklist, one had to wonder how the old Time Out made care any safer.

The senior RN in charge of an operating theatre has many responsibilities related to providing safe patient care. In this position, I need to be a role model, educator and mentor for the nurses I am responsible for. Discussing the rationale for the checklist with the quality team helped me recognise that, as health professionals, we were potentially putting the lives of patients at risk while they were in our care. They gave me a number of evidence-based articles on why change was required. With this new knowledge, I was confident in explaining to my colleagues the need to change practice for the well-being of our patients.

I was also fortunate to attend the Health Roundtable meeting in May 2010 where the Surgical Safety Checklist was discussed. I heard first-hand from New Zealand health professionals who had conducted the initial WHO pilot study to introduce the checklist. The results and benefits were clearly outlined, which motivated me to take their experiences back to my team and focus on ensuring implementation of the checklist succeeded.

Patients more involved

Patients coming into theatre now have a greater opportunity to participate in their own health care, as required by Te Tiriti o Waitangi. The patient is awake and without any mind-altering medication when he or she is checked in. The anaesthetic nurse, when doing the checklist with the anaesthetist, ensures the patient is involved in their care by getting them to tell their name and details, their understanding of the operation they are about to have, and where on/in the body we are going to operate, rather than just asking the patient, "do you know why you are here today?"

The benefits of this involvement have been apparent in the short lime the checklist has been operating. Patients have pointed out the incorrect marking of an operation site, eg a middle finger may have been marked, when in fact it was the ring finger that had been injured. By involving the patient and explaining why the check is being done, the patient can feel they have been involved in their health care plan, and the process enhances their cultural safety.

By involving patients directly in their care and discussing each patient with all the team members, the principles of Te Tiriti o Waitangi are acknowledged. By involving patients, the principle of partnership is endorsed, as the patient becomes an equal, (2) and therefore an important person in the provision of his or her own care. From when the patient arrives in the operating theatre until their transfer to the recovery room, it is my responsibility as an RN to ensure they are in a safe environment. By doing so I am advocating for my patient, ensuring their protection from harm, as required by Te Tiriti o Waitangi. (2)

Evidence suggests a large proportion of surgical mishaps can be avoided (3) (though it is acknowledged complications in surgery, or even death, can occur even with all due preventable care administered). A recent report on the effectiveness of the checklist has shown a reduction in reported surgical incidents for the period May 2010 to September 2010. (4) In the same period in the years 2008 and 2009, the numbers of reported incidents were 12. In 2010 that fell to 11 reported incidents. These figures appear to support Haynes et al (3) who say that introducing the checklist brings about a reduction in the numbers of complications or even deaths.

The checklists done by our surgical teams have helped reduce complications and enhance patient well-being, so the benefits are already showing. The patient has safer surgery and a shorter stay in hospital, which in turn frees beds and operating theatres for other patients, thereby reducing waiting lists.

The community benefits as the patient returns home sooner to become an active, participating member of the community again. Research has shown there is a negative impact on patients, their families and community when hospital stays are unnecessarily extended. (5)

The hospital's quality team, which introduced the Surgical Safety Checklist, is also monitoring completed checklists and can see where improvements need to be made. Using that, and feedback from staff, they have updated the forms accordingly and at the time of writing, the checklist is up to version 11 and is nearing the point of becoming part of legal hospital documentation. The checklist will eventually become part of the patient's notes, once this is approved by the hospital's governance committee.

Once completed in theatre, the checklists are kept in recovery for collation and auditing. If part of the form was not completed, the quality team find out why. With checklists kept in patient's notes, this documentation can show what was done in theatre to keep the patient safe in the event of an investigation.

The introduction of the Surgical Safety Checklist, has, in my opinion, been a success, as shown by the WHO studies that indicate many lives can be saved by taking a few moments in theatre to use the checklist.

When the checklist was first introduced, staff were anxious and somewhat apprehensive, but it is now an established step in an operation and is carried out with confidence, in the knowledge that positive outcomes for the patient are more likely than if the checklist was not used. The checkout enables the team to discuss the case, and how well it went. If there were any issues, then we, as nurses and members of the multidisciplinary team, can reflect on what went right, what didn't go so well and how we could have improved on what we did and apply that to future operations.

This article has been reprinted, with permission, from the June 2011 issue of The Dissector. Its author, Mark Bittle, won best Dissector article for 2010/2011 for this piece,


(1) World Alliance for Patient Safety, (2008) WHO guidelines for safe surgery. Geneva: World Health Organisation.

(2) Durie, M. (2003) Whaiora: Maori Health Development (2nd ed). Auckland, NZ: Oxford University Press.

(3) Haynes, A., Weiser, T., Berry, W., Lipsitz, S., et al. (2009) A Surgical Safety Checklist to Reduce Morbidity and Mortality in a Global Population. The New England Journal of Medicine; 360:5, pp491-499.

(4) Counties Manukau District Health Board. (2010) Reported Incidents--Surgical Safety Checklist Related. Auckland, New Zealand: Oxford University Press.

(5) Yu, S., Ko, I., Lee, S., Park, Y. & Lee, C. (2011) A unit coordinator system: an effective method of reducing inappropriate hospital stays. International Nursing Review; 58, ppg6-102.

Mark Bittle, RN, PG Cert(HealthSci), works as a senior nurse in the plastics operating theatre at Middlemore Hospital, Auckland.
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