Your life in WHO's hands: the World Health Organization surgical safety checklist: a critical review of the literature.
Abstract: Safe surgery is a world-wide recognised issue. The World Health Organization statistics show that the occurrence of major complications is between 3 and 16%, and the occurrence of disability and death is between 0.4 and 0.8% (WHO 2009).

According to Vijayasekar and Steele (2009) 234 million major surgical procedures are undertaken globally each year. The National Patient Safety Agency (NPSA) has collated over 1 million reports of surgical incidences in England and Wales between October 2006 and September 2007. Weiser et al (2008) quote a world-wide figure of 7 million individuals affected with a disabling complication, and a death rate of 1 million.

KEYWORDS Patient safety / Teamwork / Communication
Subject: Practice guidelines (Medicine) (Usage)
Preoperative care (Analysis)
Preoperative care (Methods)
Author: Jones, Susan
Pub Date: 08/01/2011
Publication: Name: Journal of Perioperative Practice Publisher: Association for Perioperative Practice Audience: Academic Format: Magazine/Journal Subject: Health; Health care industry Copyright: COPYRIGHT 2011 Association for Perioperative Practice ISSN: 1750-4589
Issue: Date: August, 2011 Source Volume: 21 Source Issue: 8
Topic: Event Code: 360 Services information
Organization: Organization: World Health Organization
Geographic: Geographic Scope: United Kingdom Geographic Code: 4EUUK United Kingdom
Accession Number: 272168036
Full Text: Sax (2009) states that the 'art' of healthcare and surgical care provision now encompasses such a degree of variation and complexity that it involves an increased risk of errors occurring (Nilsson et al 2010). Weiser et al (2010) agree that individuals awaiting surgical intervention are at increased surgical risk due to the complex issues of staff co-ordination and time constraints which, cumulatively, are a potential factor for errors and omissions. This is supported by Arora et al (2010) who state that studies (Thomas et al 2000; Wanzel et al 2000) have demonstrated that the operating room is a common place for errors. Not all errors are preventable, but according to Seifert (2009) and Haynes et al (2009), more than half of the errors occurring during surgery are preventable. According to Brady (2009) human error occurs when there is a breakdown within a process.

The aviation industry, much like healthcare, involves highly skilled professionals working and interacting in risky situations. To reduce adverse risks the aviation industry deploys a checklist system (Kao & Thomas 2008). According to Sax (2009) when checklists are used within healthcare they can reduce the risks, morbidity and mortality. Checklists are acknowledged as an organised system for a safe ending of a task. This is agreed by Karl (2009) who reminds us that checklists are not merely a 'to do' list but are a methodical approach to ensure that important safety identifiers have been checked and collated correctly.

Through the research of Dr Atul Gwande (WHO 2008) common occurrences of harm to the surgical patient were identified and the results demonstrated the necessity of a checking safety tool. The World Health Organization Surgical Safety Checklist was launched in 2008 and is now used by over 300 care organisations world-wide (Wilson & Walker 2009). In Wales the NPSA and the 1000 Lives Campaign released a patient safety alert in 2009 which drew attention to the importance of using the WHO safety checklist (Watson 2009). Within this author's workplace the checklist has now become a fundamental component of the surgical patient's care to ensure their safety. However, a review of the literature surrounding the use of the checklist has demonstrated several key themes that are instrumental in ensuring that its use is safe and appropriate. The literature strongly addresses the principles of communication and teamwork. Therefore, this article aims to critically analyse these themes and their relevance to the WHO checklist.

Search strategy

The literature search for this article included the data bases and search engines: CINHAL, British Nursing Index, Ovid Medline, Google and the WHO web site. Search terms utilised to explore the literature were safe surgery, safety, theatre, patient safety, theatre checklists, surgical safety and surgical care. The literature review included both English and international studies and the inclusion criteria were: English language to minimise translation costs (Lavin et al 2005), and adult only research.

The literature search includes studies dating from 2000 to 2010. These dates were deemed the most appropriate as they include the date that discusses the origins of the WHO checklist. Fifty three articles were found with relevance to the subject being reviewed, however 43 were considered to be the most applicable as they discussed issues around the checklist both positively and negatively. Teamwork and communication were also discussed. To ensure the application of sound research the Critical Appraisal Skills Programme (CASP) framework was used to critique the articles to ensure their suitability for inclusion in the literature review. A plethora of information was found surrounding the safety of the patient whilst in hospital, and why using a surgical safety checklist would further enhance patient safety. Eighteen articles were used within the introduction and literature review. Common themes identified within the literature were teamwork and communication and this article will focus on reviewing these themes. To ensure critical analysis of these themes 18 articles were reviewed to encompass teamwork and seven articles were reviewed discussing communication.

Literature review and theme analysis

In January 2007 the WHO World Alliance for Patient Safety introduced standards that would improve the safety and care of surgical patients (Donaldson 2008). It was from these standards that the WHO Surgical Safety Checklist was developed with the purpose of reducing surgical complications world-wide (Haynes et al 2009). The checklist is a three step safety document which is user friendly and practical enough allowing adaptability to suit any theatre environment world-wide (WHO 2009).

Teamwork

Use of the checklist, according to WHO (2009), involves a logical sequence of steps by a team of professionals working together for the benefit of the patient. However Russell (2008) states that team working within a theatre environment is not a tradition encompassed within healthcare; traditionally, theatre is an environment led by the consultant surgeon. The development of the WHO checklist has identified that teamwork is instrumental in minimising surgical risks. This is agreed by Sax (2009) who states that the WHO checklist is instrumental in ensuring for the first time that nurses, anaesthetists and surgeons have agreed on a minimal standard of care to ensure patient safety.

According to WHO (2009) teamwork within a theatre setting is central in ensuring that systems involving multiple people are effective. The theatre environment involves multi disciplinary team members, with each individual having equal importance in providing expert care. This is agreed by Watson (2009) who states that the purpose of an operating team is to enhance the quality of care provided to the patient. According to Kao & Thomas (2008) surgical errors are attributed to individuals as opposed to one individual. These authors believe that a well functioning team is the way to minimise these risks.

Sustainability of teamwork is centred on a plethora of skills including communication, awareness and clinical competency (WHO 2009). According to Rayner (2009) teams using the WHO checklist are better prepared, less rushed and more professional, which in turn demonstrates enhanced accountability and mutual respect for each team member's role. Rayner (2009) also states that a team briefing at the beginning of the day, as per the WHO checklist guidance, facilitates team introductions and embraces a respected familiarality, creating a less stressed environment. This is supported by Wilson and Walker (2009) who document that team briefing is specifically beneficial to junior members of the team as it allows them the comfort of accepted communication in the form of questioning and raising concerns (Lingard et al 2008). However, it has been debated whether the time taken for the 10-15 minute briefing could be better used by talking to the patient thereby minimising their anxieties (Malkin 2000, Mitchell 2007).

According to Bickell et al (2006) the operating room is an area of uncertainty, multiple demands and ever changing teams. This has resulted in the environment being dependant on the surgeon which may result in human error due to the added pressure placed on him or her. Vijayasekard and Steel (2009) state that using the checklist with an inadequate team or a team who has had no training may result in checklist fatigue and therefore the checklist may be viewed as a tick box exercise which may influence professional and clinical judgement and decision making. This supported by Davies (2005) who states that a well established team needs to be supported by a pro-active leader who takes responsibility for training and development. Interestingly, there was no evidence within the literature to support the need for training of staff to use the WHO checklist and therefore it should be the responsibility of each organisation to initiate training to ensure the safe use of the checklist.

Weiser et al (2010) carried out a prospective study of 1750 surgical interventions at the eight hospitals piloting the WHO checklist and concluded that improved interaction between the team had minimised potential risks. The authors acknowledged however that improvement in the team dynamics may have resulted from the Hawthorne effect of being observed. However, it could be argued that being observed may have had the opposite effect of improved performance, as nervousness and the anxiety about being observed may also have influenced performance. Therefore contrary to Weiser et al's (2010) suggestion, it could be argued that individual autonomy and accountability are the individual drivers of team members. Medics and nurses are constantly observed during training and therefore the team dynamics may have improved due to the need to ensure optimal delivery of the checklist to ensure patient safety.

Mazzocco et al (2009) in their study of team behaviour and comparable patient outcomes identified lower rates of surgical complications when team members shared information and were assertive. A study by Vincent (2010) to measure team performance stated that dynamics of a team are dependant on: the infrastructure of the team, the skills within the team, the environment they work in, the sharing of information, teamwork guidelines and the appreciation of each others' roles. The difficulty with this research was that it only observed 50 surgical procedures and therefore it is questionable whether the results can be generalised. The assessment tool was one that the authors had devised themselves and therefore the reliability of the tool and the validity of the results also need to be questioned.

Reliability of questionnaires is demonstrated through the piloting of the questionnaire prior to it being used in research. This ensures rigor that the sample group piloted is representative of the research sample (Cormack 2000, Parahoo 2006).

Theatre teams, according to WHO (2009), are not provided with structure or guidance to ensure that the team is adequate and functional. WHO (2009) therefore argues that the risks to patients remain. If team dynamics within the theatre department are not optimised due to the failure of the establishment who employs them, then surely infrastructures should be identified to ensure best practice. Research suggests the effectiveness of courses, identification of a team leader, development of team building skills and effective communication will enhance teamwork (Davies 2005, Wilson & Walker 2009). Communication

According to Marshal and Manus (2007) faulty communication within a theatre environment has resulted in human error, and poor communication is the main cause of 70% of sentinel events within healthcare (WHO 2009). WHO (2009) states that the imparting of knowledge and the way that information is communicated are pivotal to patient safety. Rayner (2009) argues that patient safety is not solely dependant on what is communicated but also on the amount of communication that takes place.

Via a randomised, quantitative piece of research Nundy et al (2008) developed a theatre briefing tool, its aim being to optimise communication within the team. The researchers believed that using this tool would have a positive impact on theatre efficiency. The results showed that, following the assessment of the healthcare provider using the briefing tool, a marked increase in effective communication occurred which resulted in less surgical delays. Although this research supports operating team briefings prior to surgery, the results appear biased, as the sample group numbers were more medically favoured as opposed to an even balance of all team members.

Pronovost et al (2006) document that adverse event reports indicate that poor communication along with teamwork problems are commonly found to be contributory factors (i.e. present in 22-32% of reports). However, these authors state that communication is the crux of healthcare provision. This is agreed by Lingard et al (2004) who via an observational study found a 30% failure in communication during surgical procedures which culminated in a 36% practice consequence such as tension within the team, patient transfer delays and procedure error.

Through a longitudinal, quantitative prospective study of how a preoperative checklist and team briefing exercise can minimise errors in communication, Lingard et al (2008) concluded that errors in communication declined following the intervention. Critical review of this piece of research indicates a comprehensive and well constructed research. It agrees with the research by Nundy et al (2008) that poor communication can result in theatre delays and increased adverse incidences. In contrast to the study by Nundy et al (2008), Lingard et al (2008) ensured an appropriate balance of team members i.e. surgeons, anaesthetists and nurses within the sample group. However, this research was submitted for publication in 2006, prior to the launch of the WHO checklist. It does however appear to be supportive of the World Health Organization research.

Conclusion

Eight million surgical interventions occur in the United Kingdom annually (NPSA 2008) and over 230 million surgical procedures are carried out worldwide (Russell 2008). Unsafe healthcare underpins morbidity and mortality, and statistics by the NPSA (2008) state that over one million surgical incidences occurred in England and Wales between October 2006 and September 2007. These figures instigated a WHO World Alliance for Patient Safety in 2007 with the aim to develop core standards to reduce surgical mortality and morbidity. The tool formulated to minimise surgical incidences was the implementation of a surgical checklist which would be utilised globally (Vijayasekar & Steele 2009).

The WHO Surgical Safety Checklist is designed to enhance both communication and teamwork and to ensure that healthcare professionals deliver evidence based patient care (Anderson 2009, Wilson & Walker 2009). Research by Bell (2010) states that, not only did use of the checklist improve communication, but also the team infrastructure improved as there was greater understanding of each others' roles. However, Sax (2009) suggests that appropriate use of checklists requires the team to be provided with appropriate training to ensure safe utilisation (Vijayasekar & Steele 2009).

The Critical Appraisal Skills Programme framework poses the question of whether implementing the research findings would be beneficial when considering harm and costs. It is clear in the literature that the WHO Surgical Safety Checklist is pivotal to ensuring patient safety and that harm is reduced through enhanced teamwork and communication. The cost here is not only financial; as individuals we are accountable for our practice and as such we need to ensure that we continue to apply best practice to ensure patient safety.

Surgical errors, according to WHO (2009) and Weiser et al (2010) are preventable. If used properly the WHO Surgical Safety Checklist, through effective teamwork and communication will result in the right patient, having the right procedure, at the right time in the right area (Donaldson 2008).

No competing interests declared

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Correspondence address: Correspondence address: Susan Jones, Abertawe Bro Morgannwg University Local Health Board, Swansea, SA6 6NL Email: susan.jones39@wales.nhs.uk

About the author

Susan Jones BSc Nursing, Diploma in Health Care Studies

RGN and Practice Facilitator, Abertawe Bro Morgannwg University Local Health Board, Swansea
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