Use of a Surgical Safety

Checklist to Improve Team

Communication
RICHARD A. CABRAL, DNP, CRNA;
TERRY EGGENBERGER, PhD, RN, NEA-BC, CNE, CNL;
KATHRYN KELLER, PhD, RN, CNE;
BARRY S. GALLISON, DNP, MS, APRN-BC, NEA-BC, CPHQ, AHN-BC;
DAVID NEWMAN, PhD

ABSTRACT
To improve surgical team communication, a team at Broward Health Imperial Point Hospital, Ft
Lauderdale, Florida, implemented a program for process improvement using a locally adapted World
Health Organization Surgical Safety Checklist. This program included a standardized, comprehensive
time out and a briefing/debriefing process. Postimplementation responses to the Safety Attitudes
Questionnaire revealed a significant increase in the surgical team’s perception of communication
compared with that reported on the pretest (6% improvement resulting in t79 ¼ e1.72, P < .05, d ¼ 0.39).
Perceptions of communication increased significantly for nurses (12% increase, P ¼ .002), although
the increase for surgeons and surgical technologists was lower (4% for surgeons, P ¼ .15 and 2.3%
for surgical technologists, P ¼ .06). As a result of this program, we have observed improved surgical
teamwork behaviors and an enhanced culture of safety in the OR. AORN J 104 (September 2016) 206-216.
ª AORN, Inc, 2016. http://dx.doi.org/10.1016/j.aorn.2016.06.019
Key words: communication, teamwork, safety, WHO Surgical Safety Checklist.

E ffective surgical team communication is vital to

creating a reliable culture of safety in ORs. In 2000,
the Institute of Medicine released its sentinel report,
To Err is Human: Building a Safer Health System, showing
alarming statistical data from two major studies by the
Sentinel events continue to occur in the United States. The
national incidence rate of wrong-patient, wrong-procedure, or
wrong-site surgery is estimated to be as high as 50 per week.3
The Emergency Care Research Institute extrapolated data
from the Pennsylvania Patient Safety Authority in 2012 and
American Hospital Association.1 These studies revealed that estimated that the annual number of surgical fires in the
“at least 44,000 people, and perhaps as many as 98,000, die United States is approximately 200 to 240.4 The Joint
in hospitals each year as a result of medical errors that could Commission recently reported that the most frequently
have been prevented.”1(p1) The Institute of Medicine identified root causes of sentinel events are human factors,
affirmed high error rates are most prevalent in intensive care leadership, and communication.5 Furthermore, the Joint
units, ORs, and emergency departments.1 Unfortunately, Commission’s 2016 National Patient Safety Goals include
more than a decade later, these numbers may be even improving communication and implementing the use of
higherdbetween 210,000 and 440,000.2 a protocol to prevent wrong-site, wrong-procedure, and
http://dx.doi.org/10.1016/j.aorn.2016.06.019
ª AORN, Inc, 2016
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September 2016, Vol. 104, No. 3 Use of a Surgical Safety Checklist

wrong-person surgery.6 Conceivably, implementing a program strengthen our OR culture of safety by improving the surgical
for process improvement that improves communication could team’s perceptions of three factors: communication, team-
also improve patient safety. work climate, and safety climate.

Experts have recommended improving a culture of safety by Our next step was to review baseline data from the hospital’s
upgrading safety practice procedures and using existing AHRQ Patient Safety Culture Survey from 2013. The results
evidence-based programs. Early reports from the Institute of of the survey revealed that staff members’ perceptions of
Medicine made recommendations for health care providers to communication, teamwork, and patient safety were below
implement systems to ensure safety practices at the delivery the national average. We also reviewed our OR staff member
level.1 The Agency for Healthcare Research and Quality satisfaction survey from 2014, which revealed opportunities
(AHRQ) recommended improving the culture of safety in for improvement in staff members’ perceptions of commu-
health care through efforts aimed at the prevention of nication and teamwork. For example, 56% of staff members
procedural error.7 (n ¼ 27) who responded felt that their colleagues did not
display a positive attitude, which affects teamwork and
Within the past several years, leading health care organizations communication. We determined that a program for process
have recommended multiple programs to improve a culture improvement that addresses these three factors could
of safety. In their Correct Site Surgery Tool Kit, AORN improve the OR culture of safety and help prevent adverse
offers a comprehensive surgical checklist that incorporates surgical outcomes.
elements of the World Health Organization (WHO) Surgical
Safety Checklist (SSC)8 and recommendations from The Before initiating this program, the surgical teams at our hos-
Joint Commission.9,10 The AHRQ and the Department of pital were using The Joint Commission’s Universal Protocol13
Defense also developed an evidence-based patient safety time out process. The protocol helps staff members ensure that
program called TeamSTEPPS.11 These organizations developed the right procedure is being performed on the right patient at
these tools to promote patient safety,12 and these programs the right surgical site.13 This process was already used in our
include recommendations to use leadership and communication OR; however, the WHO SSC was not. Therefore, the use
tools, such as the WHO SSC, to improve surgical team of the WHO SSC was an opportunity for our surgical teams
communication. to focus intentionally on communication to minimize
human error.
Our locally adapted SSC was developed to improve our
facility’s culture of safety by following recommendations The Joint Commission specifically mandates completion of a
from The Joint Commission’s 2016 National Patient Safety time out to prevent mistakes in surgery.6 The time out process
Goals6 and the AHRQ, which support mechanisms such as can be enhanced by using the WHO SSC, which involves
a briefing/debriefing process that improves surgical team three checkpoints, including items that must be addressed
communication, collaboration, and the relaying of accurate by team members
patient information.
 before the induction of anesthesia,
DESCRIPTION OF THE PROBLEM  before the incision is made, and
 before the patient leaves the OR.8
A process improvement team was formed at Broward Health
Imperial Point Hospital in Ft Lauderdale, Florida, to We decided to adapt the checklist as an extension of The Joint
strengthen the OR culture of safety. This team consisted of a Commission’s time out protocol. Our checklist incorporated a
program leader, facility champions, mentors, and a statisti- recent adaptation of the WHO SSC developed by the Safe
cian. The chief nursing officer and the regional director of Surgery 2015 program, which includes a briefing and
quality and safety supported and validated our interest. We debriefing process.14 The process improvement team also
developed a program incorporating a modified version of the added the following items to our checklist based on a
WHO SSC into our OR practice. The impetus for this perceived need:
program originated after our program leader was asked to
provide education to staff members on OR fire safety. This  a fire risk assessment to be discussed during the time out
prompted an evaluation of tools to further promote a culture briefing, and
of safety in our OR. The goal of this program was to evaluate  an opportunity to express gratitude to encourage teamwork
whether the incorporation of the WHO SSC could and caring to be completed during the debriefing.

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LITERATURE REVIEW one cystoscopy room and seven general surgery rooms, one
We reviewed three classic studies showing improved outcomes of which is a robot-assisted suite. The OR hosts 15 different
related to perceptions and communication after using the surgical specialties, and it completes approximately 7,200
WHO SSC or a similar locally adapted checklist. These studies procedures annually.
also suggested a causal relationship between improved
communication and improved surgical outcomes.15-17 THE INTERVENTION TOOL
The WHO SSC, a communication tool with a successful track
Haynes et al15 conducted an international pilot study that
record,18 involves a standardized surgical checklist to minimize
examined the effectiveness of the WHO SSC in the prevention
human error. The checklist has been shown to reduce
of surgical complications. The authors hypothesized that the
mortality rates by improving communication, teamwork
implementation of the checklist, plus the associated changes in
climate, safety climate, and surgical outcomes.15-18 In 2008,
culture it signified, would reduce mortality rates. Mortality
the WHO’s World Alliance for Patient Safety launched the
rates decreased from 1.5% before implementation of the
“Safe Surgery Saves Lives” initiative and developed the
checklist to 0.8% (P ¼ .003) after implementation.15 This
WHO SSC as an effort to improve communication between
study showed that the introduction of the WHO SSC into OR
surgical team members to prevent surgical complications.19
procedures had a significant effect on surgical outcomes.
Our locally modified checklist consists of three parts. The first
Nilsson et al16 conducted a staff member survey after using a
part occurs before the induction of anesthesia, and it includes a
locally developed checklist. The checklist evaluated each staff
time out in the OR with the patient, anesthesia care provider,
member’s attitude toward the checklist regarding patient
nurse, and surgical technologist. The second part occurs before
safety.16 Of 331 respondents, 65% reported that it
the surgical incision, and it includes a briefingda role-based,
strengthened the OR team, 86% reported that it helped
comprehensive time out that prompts all team members, one
solve problems, and 93% reported that it added to patient
at a time, to stop and introduce themselves and describe
safety.16 This study supported using a locally modified
their roles. This part of the checklist formally recognizes and
version of the WHO SSC as a way to improve perceptions
empowers each team member, thereby encouraging active
of teamwork climate and safety climate in the OR.
engagement and the sharing of critical facts. The surgeon shares
A follow-up study by Haynes et al17 strongly suggested that the operative plan, the anesthesia care provider shares the
improved perceptions of teamwork climate and safety climate anesthetic plan, the RN circulator and the surgical technologist
have a positive effect on surgical outcomes. In this study, a confirm the sterility of instruments, and the team conducts
modified version of the Safety Attitudes Questionnaire (SAQ) a fire risk assessment, following recommendations from
was given to staff members before and after implementing an AORN’s Fire Risk Assessment Tool.20 The surgeon prompts
SSC, to understand the attitudes and perceptions of clinical team members to speak up with any concerns for patient
teams who used the SSC. The objective was to assess the safety. This briefing process ensures that every OR team
relationship between changes in clinician attitude and changes member is in agreement before the procedure begins. Finally,
in postoperative outcomes.17 The survey results indicated that the third part of the checklist is completed before the patient
the use of the checklist improved SAQ scores.17 The study leaves the OR, and it includes a debriefing. The team addresses
found that team member perceptions of communication, specimen labeling, instrument counts, and other concerns,
teamwork, and safety climate improved after implementation such as equipment issues. The surgical team members express
of the WHO SSC and that the change correlated to gratitude for a job well done, reinforcing an environment of
improvements in patient morbidity and mortality.17 Therefore, teamwork and caring. Of particular importance to our program
positive changes in SAQ scores can be a benchmark of effective was the briefing and debriefing process, which encouraged
implementation of the WHO SSC. communication, a just culture, and empowerment of surgical
team members to speak up for patient safety.

DESCRIPTION OF THE PROGRAM INTENDED OUTCOMES

SETTING The expected, measurable outcomes of this process improve-
This evidence-based program for process improvement was ment program included the following:
conducted in the ORs at Broward Health Imperial Point
Hospital. This hospital is an acute care, 204-bed community  the SSC will be implemented on a limited scale (ie, in 10% of
facility. The department consists of eight ORs, including OR procedures performed) before a systemwide rollout; and

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 surgical team members will complete the SAQ, report- weeks in the second quarter of 2015. We maintained survey
ing perceptions of improved communication, teamwork anonymity by collecting questionnaires in sealed envelopes
climate, and safety climate, before and after implementation and avoided assigning unique identifiers to the pretest SAQs.
of the SSC. The pretests were made anonymous in our effort to improve
both the number of participants and the honesty of their re-
METHODS sponses. Participants deposited the sealed envelopes in a
This was a single-group, pretest/two-month intervention/ designated, secure lockbox. We administered the SAQ to
posttest design to investigate the effectiveness of our locally surgical teams in staff meetings or in one-on-one interactions
adapted checklist. The program’s design was approved through before and after implementing the SSC intervention. The
an accelerated review process developed by the institutional SAQs were not numbered, so it was not possible to correlate
review board and the Christine E. Lynn College of Nursing at specific responses from a participant’s pretest and posttest.
Florida Atlantic University. Therefore, the independent sample estimates of change are
more conservative and less powerful than estimates that would
have been obtained from a dependent or paired method of
Measurement analyzing the data.
We used the OR version of the SAQ as our measurement
tool.21,22 Health care organizations use the SAQ to measure
caregiver attitudes regarding six patient safety factors (ie, Data Analysis Methods
teamwork climate, safety climate, job satisfaction, perceptions We entered the data into SPSS version 23 and analyzed it
of management, working conditions, and stress recognition).22 using independent sample t tests. We used an independent
In addition, the OR version of the SAQ includes a sample t test to compare mean changes in SAQ scores from the
collaboration and communication section where respondents pretest to the posttest, and we calculated Cohen’s d effect size.
indicate the quality of communication they have experienced We performed a one-tailed test of statistical significance to test
with each type of provider in the OR.21 The SAQ is used the hypotheses using a ¼ e0.05. An evaluation of the mean
to prompt interventions that improve patient safety attitudes SAQ scores allowed us to correlate the change in safety per-
and to measure the effectiveness of these interventions after ceptions that occurred after implementing the SSC interven-
implementation.22 The OR version of the SAQ includes 60 tion tool.
items, plus demographic information.22 Each of the 60
items is structured as a five-point Likert scale.22 According IMPLEMENTATION
to Sexton et al,22 psychometric properties of the SAQ The program’s implementation took place in three phases
instrument tool have been analyzed and reported, showing during a four-month period. Our process improvement team’s
evidence of validity and reliability. Sexton et al22 assessed certified RN anesthesia care provider was the program leader
composite scale reliability for the SAQ to be 0.90 (using and change agent. Phase I lasted one month and consisted of
Raykov’s r coefficient), indicating strong reliability. This our program leader administering the preintervention SAQ
finding in conjunction with multilevel factor analysis and disseminating information. Nurses, surgical technologists,
demonstrated the SAQ’s validity.22 and surgeons completed the SAQ on a voluntary basis. Next,
at a staff meeting on evidence-based research regarding use of
Sample the SSC in practice, the program leader gave a presentation
We obtained a voluntary response sample of surgical team and showed a video on how to use the WHO SSC. Beyond
members in our OR department. The strategy was to recruit this, the program leader showed surgeons how to use the
participants to complete a pretest and posttest SAQ through WHO SSC through both one-on-one conversations and poster
fliers, posters, formal staff meetings, and informal one-on-one presentations.
encounters during daily OR practice. Participants included Phase II lasted two months and consisted of implementing the
surgeons, nurses, and surgical technologists. locally adapted checklist. We used the checklist throughout
our eight ORs in all surgeries in which the program leader was
Data Collection Methods present as a part of the surgical team. This intervention phase
Pretest data were collected during two weeks in the first also included one-on-one training (when necessary), infor-
quarter of 2015, and posttest data were gathered during two mation sharing, and feedback. Furthermore, the program

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leader kept a log of all procedures in which our WHO SSC the means and standard deviations for age, years in specialty,
intervention tool was used. and years at the hospital.

Phase III, which took place in the final month, consisted of Table 4 shows that communication had the highest internal
administering the postintervention SAQ to measure team consistency (a ¼ 0.79). Both teamwork climate and safety
members’ perceptions and to identify the number of surgical climate had a lower but acceptable internal consistency
team members who actually used the WHO SSC in practice. estimate (a ¼ 0.69). Table 5 shows a 6% increase in
We accomplished this by asking the participants to place an communication as measured by SAQs from pretest to
asterisk on their questionnaire if they had used the checklist. posttest, from an average score of 60.81 to 64.68, resulting
The results of the preintervention and postintervention SAQs in a significant difference (t79 ¼ e1.72, P < .05). There are
were compiled, and we performed statistical data analysis 15 items on the OR version of the SAQ related to
to measure the outcomes of the program. In addition to communication, and the range of scores for communication
this three-phase overview, we have constructed action steps is 15 (very low) to 75 (very high).
to assist others in replicating this program (Table 1).
Cohen’s d is a measure of effect size or magnitude with a
value of 0.2 indicating a small effect, a value of 0.5 indicating
Barriers to Change a medium effect, and a value greater than 0.8 indicating a
To overcome resistance and barriers to implementation, we large effect. For communication, Cohen’s d equaled 0.39,
used an established framework for effective change and actively which indicates a smaller medium effect. This effect is
rallied an implementation team. We used John Kotter’s quite meaningful, considering that the checklist was used in
contemporary change model,23 an eight-stage model that only 10% of the surgical procedures across two months.
comprises creating a sense of urgency, building a team, It indicates that if this checklist had been used in more surgical
developing a strategy, communicating the change vision, procedures during an extended time period, the effect on
empowering action, creating short-term wins, persevering, and perceptions of communication would have been greater.
anchoring the change.23 Our implementation team consisted Perception of teamwork and safety climate decreased from
of the program leader, nurses, surgical technologists, surgeons, pretest to posttest, but not significantly (P ¼ .29 and P ¼ .48,
the regional quality/safety director, the unit-based council, the respectively).
chief of anesthesia, the chief of surgery, a surgeon champion,
the OR director, and the OR nurse manager. Members of the Nurses’ perception of communication increased the most
implementation team actively promoted our checklist to help (12%, t64 ¼ e3.01, P ¼ .002, d ¼ 0.75) from pretest to
establish buy-in from staff members. In addition, our program posttest. The increase for surgeons (4.0%) and surgical tech-
leader and our surgeon champion conducted one-on-one nologists (2.3%) was indicative of an improvement, but was not
conversations with senior leaders and surgeons. Designating significant (P ¼ .15 and P ¼ .06, respectively). Table 6 shows
one surgeon as a champion to act as a catalyst was critical for the mean scores of perceptions of communication on pretests
obtaining buy-in from the rest of the surgeons. and posttests. Figure 1 displays these results graphically.

Some anecdotal comments from staff members are also worth

RESULTS considering. In the preintervention and postintervention
The SSC was used in 10% of all surgical procedures during SAQs, surgeons and nurses had the option to write comments
two months in a total of 103 surgeries. Of 114 surgical team and recommendations for improving safety in the OR.
members, 30% reported using the SSC in practice. The total On the pre-SAQs, two surgeons recommended including
number of SAQs received was 93. Approximately 41% of “an intraoperative time out briefing” and “communication,
surgical team members completed the pretest (47 surveys) and consistency, and cooperation.” Comments and recommenda-
approximately 40% of surgical team members completed the tions on the post-SAQ are included below.
posttest (46 surveys). Surgeons completed 19 surveys, surgical
technologists completed 21 surveys, and nurses completed  “The SSC is well thought out, easy to follow, and it gave us a
33 surveys (the remaining 20 surveys had unreported de- good evidence-based practice tool to utilize in our OR
mographic data). Table 2 presents demographic characteristics setting.”
of participants. Most respondents were female, white, and full-  “Use the safety checklist (briefing) and encourage dialogue of
time employees, and most worked day shifts. Table 3 presents all members in a team approach.”

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Table 1. Recommended Implementation Plan

Timeline Recommendation Action Steps

Phase I (preintervention),  Obtain baseline data on  Administer a preintervention Safety
weeks 1-2 desired outcomes. Attitudes Questionnaire (SAQ) to the
surgical team on a voluntary basis in formal
and informal staff meetings by placing
surveys in staff lounges. Collect responses
before educating the OR team. Develop a
process to link pretest and posttest survey
results to measure individual change.
 Place surveys, pencils, and a secure lockbox
in the staff and surgeon lounges to collect
the SAQs.
Phase I (preintervention),  Form an implementation team.  Meet with at least 1 administrator,
weeks 3-4 anesthesia care provider, RN circulator,
surgical technologist, and surgeon to
discuss a program using the World Health
Organization (WHO) Surgical Safety
Checklist (SSC).
 Inform surgical team members  Meet with the OR unit-based council to
about a process improvement discuss developing a locally adapted SSC
program to improve surgical for use at your hospital.
team communication using the  Have 1-on-1 conversations with the OR
SSC and tailor it to the unique team and surgeons about the evidence-
needs of your OR. based practice of using the SSC to obtain
buy-in.
 Display fliers and posters throughout OR to
inform the surgical team.
 Educate staff members and  Complete a presentation on the use of the
surgeons on the use of the WHO SSC during a staff meeting and
SSC. during a meeting that will reach surgeons
(eg, a surgical monitoring committee
meeting).
 Show a video on how to use the checklist
in practice (eg, WHO Safe Surgery Saves
Lives Checklist).1 Or create your own video
with members of your OR team using the SSC.
 Allow the surgical team to  Complete a simulation with the OR team
practice using the WHO SSC. using the SSC in the OR.
Phase II (intervention),  Develop champions with  Train the trainer.
weeks 5-12 1-on-1 training.  Share information.
 Modify the checklist as necessary.
 Provide feedback to the OR team.
 Pilot the SSC in practice.  Have the program leader use the checklist in
all his or her procedures, in all ORs, with all
OR team members during a 2-month period.
 Practice using the SSC in the OR.
 Record the use of the SSC.  Keep a log of the total number of
procedures during which the SSC is used.
Phase III (postintervention),  Readminister the SAQ.  Administer a postintervention SAQ to
weeks 13-14 volunteers who completed the pre-SAQ.
Phase III (postintervention),  Analyze data.  Compile and report SAQ data to staff
weeks 15-16  Report findings. members, facility leaders, and surgeons.
Reference
1. WHO Safe Surgery Saves Lives Checklist [video]. YouTube. https://www.youtube.com/watch?v¼CIFhLUiT8H0#t¼23. Accessed May 31, 2016.

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Table 2. Demographic Characteristics of Participants Table 4. Internal Consistency of Communication,

Teamwork Climate, and Safety Climate Measured
n Percent by the Cronbach Alpha
Position
Surgeon 19 26.0 Subscale Number of Items a
Surgical technologist 21 28.8 Communication 15 0.79
Nurse 33 45.2
Not indicated 20 Teamwork climate 4 0.69
Shift Safety climate 6 0.69
Day 49 87.5
Evening 3 5.4
Variable 4 7.1
Not indicated 37 members expressed, it fostered increased confidence in the OR
Job status culture of safety.
Full-time 65 94.2
Part-time 2 2.9
Agency 2 2.9
Not indicated 24 DISCUSSION
Ethnicity Those who wish to implement a similar program for process
Hispanic 7 10.8 improvement in their own facilities should consider the factors
Black (non-Hispanic) 5 7.7 that contributed to our program’s success, the lessons learned,
White (non-Hispanic) 46 70.8
Asian/Pacific Islander 3 4.6
and the importance of disseminating results. Recent literature
Other 4 6.2 has revealed several factors that commonly lead to successful
Not indicated 28 implementation of an SSC. These include comprehensive
Sex training, a program leader, support from upper management,
Female 42 59.2 modifying the checklist, team members’ ownership of the
Male 29 40.8
Not indicated 22 change, a stepwise implementation process with real-time
feedback, and enhanced communication and teamwork.24-27
Our program successfully addressed these components, and
the results support the use of these elements in practice.
 “The checklist improves team communication . continue
the checklist enforcement.” Foremost among the factors contributing to our success was
the implementation team. Conley et al28 concluded that
Additionally, the chief nursing officer who originally encour- implementation of an SSC with a strong team effort and
aged us to strengthen the culture of safety verbally expressed to support from senior leadership was the most effective
us that “it is evident in the OR [that] there is more teamwork approach to use.28 Mahajan27 further stated that it is critical
since this program implementation has occurred.” These rec- for a team of positive adopters to be developed early to
ommendations and comments support the checklist’s value encourage surgical team participation. Senior leadership
and the program’s effect on promoting an OR culture of was crucial, so we made every effort to recruit champions
safety. Thus, not only did the program increase surgical team who were administrators, senior nurses, and surgeons.
members’ perceptions of communication, but, as some team Organizational leadership is vital in setting the tone for
implementation and change.27

Another factor that helped with successful implementation

Table 3. Means and Standard Deviations for Age, was the fact that we modified the WHO SSC to address
Years in Specialty, and Years at Hospital
the specific needs of our ORs. Treadwell et al24 emphasize
n Min Max M SD the importance of using a team-based approach when
Age, years 62 29 70 50.86 9.08
adapting a surgical checklist for a specific setting. Mahajan27
recommended modifying the WHO SSC to increase its
Years in specialty 64 1 41 21.03 11.42
relevance to local circumstances. In our program, we
Years at hospital 63 1 40 13.95 10.71
incorporated a fire-risk assessment component in response to
Min ¼ minimum; Max ¼ maximum; M ¼ mean; SD ¼ standard recent reported OR fires in other hospitals. Another
deviation.
customization to our checklist was the addition of a prompt

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Table 5. Safety Attitudes Questionnaire Scores on Communication, Teamwork Climate, and Safety Climate Before
and After Implementing the OR Checklist

Pretest Posttest t P Cohen’s d

M SD M SD
Communication 60.81 9.65 64.68 10.41 e1.72 .045a 0.39
Teamwork climate 17.06 3.19 16.68 2.85 0.56 .287 0.13
Safety climate 25.09 4.25 25.03 4.08 0.06 .477 0.01
NOTE. df ¼ 79 for all tests.
M ¼ mean; SD ¼ standard deviation.
a
P < .05.

for expressing gratitude to encourage teamwork and caring. and monitoring of the checklist’s implementation. It allowed
Staff members at our hospital have adopted Watson’s29 the program leader to act as the facilitator and mentor
theory of human caring as their theoretical framework for without pressuring other surgical team members to be
nursing in clinical practice, and the hospital has instituted a accountable.
holistic care council that encourages all departments to
create supportive, caring environments.30 This prompt on One important lesson learned concerns this stepwise imple-
our checklist creates a forum for promoting caring mentation. The approach was effective because it started small,
relationships. This was another adaptation that made the with a single program leader/trainer. In retrospect, we recog-
checklist relevant and helped secure buy-in. For those nize that the stepwise process would have been more effective
wishing to locally adapt the WHO SSC in their own if we had introduced two other steps: a simulation and a
facilities, we recommend reviewing all safety issues that have train-the-trainer process. First, it would help to begin the
occurred in their OR settings and deciding whether those implementation process by conducting simulations or mock
issues should be addressed in their process improvement surgeries in which the surgical teams rehearse the use of
programs. This will both increase a checklist’s relevance and every part of the checklist. These simulations could be con-
help secure ownership of the change. ducted during staff meetings in which participants are divided
into smaller groups. Safe Surgery 201514 developed an
Another factor contributing to our successful implementation implementation guide to teach using the checklist through
was our stepwise process with real-time feedback. Kearns scripted rehearsals.31 Using this method, each group reads
et al26 recommended starting out small to test the intervention from a script to rehearse the correct use of the checklist. We
and providing feedback before changing the already existing realized the importance of simulations after we noticed that
practice. We tested the use of our SSC with a small sample the surgical team members varied in their familiarity with
size instead of starting with a systemwide implementation. SSCs. If we had used the scripted implementation guide,31
This allowed for more organized, centralized training we could have alleviated some of this uncertainty.

Table 6. Means of Pretest and Posttest Communication Scores Disaggregated by Positions

Position Pretest Posttest t P Cohen’s d

M SD M SD
Surgeons 66.62 9 69.33 6.8 1.05 .15 0.35
Surgical technologists 61.3 3.02 62.73 2.88 1.36 .06 0.7
Nurses 55.41 7.93 62 9.76 3.01 .002a 0.75
NOTE. df ¼ 79 for all tests.
M ¼ mean; SD ¼ standard deviation.
a
P < .05.

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SAQ in the future to measure the effectiveness of a full

implementation on communication, teamwork climate, and
safety climate.

A final consideration for those who may want to implement a

program such as this one is the importance of disseminating
the results. The program leader shared the results of this
successful program locally (at an OR staff meeting, the hos-
pital’s surgical monitoring committee meeting, nursing grand
rounds, and a quality and safety symposium) and regionally via
a poster presentation. Disseminating results is important
because a program such as ours can provide an example to
other health care professionals as they wrestle with ways to
strengthen their OR culture of safety. We hope it will help
others develop their own programs to improve perceptions
Figure 1. Surgeons, surgical technologists, and nurses of surgical team communication, teamwork climate, and
reported an increase in perception of communication safety climate.
from pretest to posttest, although the change was only
statistically significant for nurses. SAQ ¼ Safety
Limitations
Attitudes Questionnaire.
Our program for process improvement had some important
limitations. The first is our small sample size. By increasing the
Second, our stepwise process could have included a train-the- sample size, we could have increased the power of our statis-
trainer approach. This might have improved our program in tical data. The sample did, however, represent the majority of
two important ways. During the simulations, we could have the OR staff nurses and surgical technologists. A second lim-
identified other potential trainers and recruited them as itation is that we cannot be certain that the improvement in
trainer champions so that the program leader was not the communication perception resulted directly from the use of
only one facilitating the use of the checklist in actual OR the SSC. Staff members who did not use the SSC also
procedures. These additional trainer champions could have completed pretests and posttests, and it is possible that they,
increased the number of surgeries in which the checklist for unknown reasons, developed improved perceptions as well.
was used, thereby increasing the potential effect of our Third, because each sample was anonymous, we were unable
program on perceptions of communication. Additionally, to tie pretest responses to posttest responses to measure each
the inclusion of multiple trainer champions could have individual’s change in perception over time. Lastly, our results
alleviated the potential for bias. The checklist was used only were based on perception only, not on surgical outcomes such
after the program leader was present in a procedure. Thus, a as morbidity and mortality, although it is worth noting that
train-the-trainer approach to the implementation plan to the literature did show that perceptions of a culture of
target surgical technologists, OR nurses, nurse anesthesia safety can positively affect surgical outcomes such as morbidity
care providers, anesthesia professionals, and surgeons is and mortality. There is clearly a need for future programs
recommended. such as this to evaluate whether using an SSC directly affects
surgical outcomes.
Another lesson we learned comes from our review of the two
perceptions that our program did not significantly affect. CONCLUSION
Despite our program’s success in affecting perceptions of The WHO SSC has been shown to improve surgical team
communication, the perceptions of teamwork climate and communication, teamwork climate, safety climate, and surgi-
safety climate were inversely affected, albeit slightly. cal outcomes. Our process improvement team has imple-
Perceptions of teamwork climate decreased by 2%, and per- mented an SSC that has positively and significantly affected
ceptions of safety climate decreased by 0.2%. The chief our surgical team’s perceptions of communication. Based on
nursing officer and the regional director of quality and safety our findings and other evidence-based conclusions, the
have noted that because of turnover, there were some new hospital is adopting the SSC in OR practice. We further


staff members on the surgical team at the time the surveys recommend that a locally adapted WHO SSC be adopted for
were distributed. Both have recommended a retest with the use throughout the hospital system.

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September 2016, Vol. 104, No. 3 Use of a Surgical Safety Checklist

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Dr Eggenberger has no declared affiliation that could be posing a potential conflict of interest in the publication of
perceived as posing a potential conflict of interest in the this article.
publication of this article.

216 j AORN Journal www.aornjournal.org