AHS Safe Surgery Checklist User Manual

AHS Safe Surgery Checklist User Manual
AHS Safe Surgery Checklist
User Manual
Version 2.0
January 20, 2010
AHS Safe Surgery Checklist Manual - 2
This manual was adapted from the WHO Guideline for Safe Surgery (2009 Edition) which can be
viewed with the Tools and Resources section of the WHO website.
Link: http://www.who.int/patientsafety/safesurgery/en
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Table of Contents
Table of Contents..................................................................................................................3
1. Introduction .......................................................................................................................4
1.1 Ten Essential Objectives for Safe Surgery ..............................................................5
1.2 Key Messages .........................................................................................................6
1.3 Frequently Asked Questions....................................................................................7
2.0 Guidelines for Use of the AHS Safe Surgery Checklist...................................................9
2.1 General Guidelines ..................................................................................................9
2.2 Impact of the Safe Surgery Checklist for High Volume Cases ..............................10
3.0 Modifying the Checklist .................................................................................................11
3.1 Guidelines for Modification of AHS Safe Surgery Checklist ..................................11
3.1.1 WHO Recommendation for Modifying the Surgical Checklist .....................12
4.0 Implementation of the AHS Safe Surgery Checklist......................................................13
4.1 Recommended Process for Implementing the AHS Safe Surgery Checklist.........13
4.2 Support for Implementing the AHS Safe Surgery Checklist ..................................14
4.3 Quality Improvement Strategies for Implementation..............................................15
4.4 Communication Strategies.....................................................................................15
4.5 Key Communication Messages to Assist with Implementation and Engagement .16
4.6 Physician Engagement Strategies.........................................................................16
4.7 Measurement.........................................................................................................17
APPENDIX I ........................................................................................................................18
AHS Safe Surgery Checklist........................................................................................18
APPENDIX II .......................................................................................................................19
Guidelines for Use of the AHS Safe Surgery Checklist (detailed) ...............................19
APPENDIX III ......................................................................................................................25
AHS Implementation Working Group Membership List ...............................................25
APPENDIX IV......................................................................................................................28
Reference Article I .......................................................................................................28
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1. Introduction
According to a study by the World Health Organization (WHO) of 6,775 operations, the
implementation of a simple checklist completed during surgical procedures reduced the overall
incidents of complications and death significantly.
Haynes AB, et al. A Surgical Safety Checklist to Reduce Morbidity and Mortality in a Global
Population. N. Engl J Med, 2009; 360; 491-9. (see Appendix IV)
Alberta Health Services (AHS) is committed to improving patient safety and the quality of care for all
Albertans. Quality and safety have been identified within the AHS Strategic Direction (2009 – 2012)
document as one of the 20 key strategic priorities for the organization.
The AHS Safe Surgery Checklist (see Appendix I) is being introduced as part of this commitment in
Alberta to assist surgical teams in reducing the number of preventable surgical complications and
further improve surgical results. The AHS Safe Surgery Checklist, while not limited to use in an
operating room setting, should apply to every patient undergoing a surgical procedure as defined
below. For the purpose of this manual the following definitions apply:
Surgical Procedure: Any procedure involving an incision, excision, manipulation or suturing
of tissue. Any invasive or non-invasive procedure that requires regional, general or monitored
anesthesia by an anesthesiologist or anesthetist, which may be performed in or outside of an
operating room setting.
Surgical Team: Comprises the surgeons, anesthesiologists, nurses, technicians, and other
personnel involved in the procedure. Alternatively, this can apply to any physician and
support staff if the procedure occurs outside of an operating room setting (e.g. procedure
rooms within the Emergency Department, Invasive Radiology, etc).
Patient: Refers to those people identified as “patient”, “client”, and / or “resident” who are
receiving or registered to receive medical treatment which may involve surgical intervention.
Family: For the purpose of this manual, a family member may include a spouse, parent,
sibling, child, guardian, or agent that have legal standing to provide consent on behalf of the
patient for a medical procedure.
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1.1 Ten Essential Objectives for Safe Surgery
To assist surgical teams in reducing the number of preventable surgical complications, the WHO as
part of their ‘Safe Surgery Saves Lives’ campaign have identified ten essential objectives for safe
surgery. These objectives were developed in consultation with surgeons, anesthesiologists, nurses,
patient safety experts and patients from around the world.
WHO Ten Essential Objectives for Safe Surgery:
Reference: adapted from: WHO Guidelines for Safe Surgery 2009
1. The team will operate on the correct patient at the correct site on the patient’s body.
2. The team will use methods known to prevent harm from administration of anesthesia while
protecting the patient from pain.
3. The team will recognize and effectively prepare for life-threatening loss of airway or
respiratory function.
4. The team will recognize and effectively prepare for risk of high blood loss.
5. The team will avoid inducing an allergic or adverse drug reaction for which the patient is
known to be at significant risk.
6. The team will consistently use methods known to minimize the risk for surgical site infection.
7. The team will prevent inadvertent retention of instruments and sponges in surgical wounds.
8. The team will secure and accurately identify all surgical specimens.
9. The team will effectively communicate and exchange critical information for the safe conduct
of the operation.
10. Hospitals and public health systems will establish routine surveillance of surgical capacity,
volume and results
AHS has adopted these ten WHO objectives as part of the AHS Safe Surgery Checklist to be
introduced to all AHS sites to help ensure the quality and safety provided to patients within surgical
services. The implementation will also support AHS sites in compliance with the anticipated new
Accreditation Canada Required Organizational Practices (ROP) Surgical Checklist standard (for
introduction in 2011). The aim of the checklist is to reinforce accepted safety practices, and foster
better communication and teamwork between clinical disciplines.
Every surgical team can improve the safety and quality of care delivered to their patients by the
introduction of the AHS Safe Surgery Checklist. This manual has been created to assist sites:
1. In understanding how to use the AHS Safe Surgery Checklist;
2. With the implementation of the AHS Safe Surgery Checklist to all surgical services within a
site;
3. Who wish to modify the AHS Safe Surgery Checklist to further improve surgical results and
decrease associated complications, while still being compliant with AHS Safe Surgery
Guidelines (see Section 2.0) and the ten essential safety objectives established by the WHO.
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1.2 Key Messages
•
•
•
•
•
•
The AHS Safe Surgery Checklist is meant as a communication tool to be used by AHS
surgical teams to help ensure the safety of its patients; it is not meant to be used as a formal
document.
AHS surgical teams can use paper, electronic or poster versions of the AHS Safe Surgery
Checklist.
The AHS Safe Surgery Checklist does not replace any existing documentation or safety
check procedures currently used at any AHS site.
AHS sites must identify a surgical checklist, which must be used by surgical teams in
compliance with Accreditation Canada ROP standard.
AHS has developed an AHS Safe Surgery Checklist (see Appendix I) for general purpose use,
which can be used by AHS sites.
AHS sites can modify or develop their own surgical checklist(s) with the following provisions:
1. Surgical checklists used by AHS sites must comply with the first eight objectives
of the WHO Ten Essential Objectives for Safe Surgery.
2. Surgical checklists used by AHS sites must encourage involvement by all
members of the interdisciplinary surgical team in the communication of safety
checks at three critical points:
o Before the induction of anesthesia (Briefing)
o Before skin incision (Time Out)
o Before the patient leaves the OR (Debriefing)
3. Modification or development of a surgical checklist(s) must involve surgeons,
anesthesiologists, and nurses and must be trialed in simulated and real-life
situations to ensure functionality.
4. AHS sites may develop more than one surgical checklist to suit the specific safety
issues related to an individual surgical procedure or set of procedures. Each
individual checklist must comply with AHS (see Section 2.0) and WHO (see Section
1.1) guidelines.
5. AHS sites that have modified the AHS Checklist or have developed their own
checklist(s) are requested to supply a copy of the checklist(s) to the provincial
zone leads (Operational and / or Clinical Quality Support Consultant) or chairs of
the Implementation Working Group for review (see Appendix IV for list of
Implementation Working Group members). The members of the Implementation
Working Group are available to support AHS sites with suggestions on
modification, implementation, communication and quality improvement. The
exception are for sites that have only made minor modifications to the AHS Safe
Surgery Checklist; specifically the addition or removal of non-bold bullet points
that this manual has identified as ‘optional’ (See Section 3.1 Guidelines for Modification of
AHS Checklist).
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1.3 Frequently Asked Questions
Q. Where did the idea of a safe surgery checklist come from?
A. The original concept of the safe surgery checklist stems from the World Health Organization's
(WHO) 2007/08 'Safe Surgery Saves Lives' campaign, which built on the experience of medical
experts, healthcare professions, safety experts and patients from around the world. The Canadian
Patient Safety Institute (CPSI) and the Royal College of Physicians and Surgeons of Canada
(RCPSC), in collaboration with 15 in-country organizations, led the Canadian adaptation of the WHO
campaign. A provincial AHS committee was established in early 2009, to develop and implement a
provincial plan for adopting the checklist within all AHS facilities. Safety checks in operating room
settings are not novel and the concept of the checklist was built on systems used internationally to
help ensure safety of surgical patients.
Q. Why should we use a surgical checklist?
A. The surgical checklist has been shown to reduce the number of preventable complications
associated with surgery by ensuring critical information is shared with all members of the surgical
team, which is aligned to one of AHS key objectives for improving patient safety and quality of care. It
also helps focus the entire team on patient safety at three critical stages during the surgical
procedure (before induction, before incision and before closing). The checklist is simply a
communication tool for members of a surgical team. It does not replace existing procedures or safety
checks, but builds on them by ensuring the entire interdisciplinary team is involved in the safety
communication at the same time.
Q. We are already very busy in the OR. Isn't this just one more task using up valuable time?
A. In actuality it may save time. Once the checklist becomes familiar to operating room teams, it
requires very little extra time to perform. The AHS Safe Surgery Checklist is intended to only take no
more than one (1) minute for each of the three stages to complete (unless issues arise), while adding
no more than two (2) minutes in total to the surgical procedure time. The checklist can save time by
identifying potential issues before they arise, ensuring better co-ordination between team members,
and minimizing delays caused by retrieving additional equipment, etc.
Q. Is the surgical checklist another document and considered part of the patient record?
A. No, the surgical checklist is not meant to serve as a formal document and is not considered
suitable for charting or recording. It is simply a communication tool to trigger members of the surgical
team to ensure critical safety checks are completed at key stages in the procedure.
Q. Will all surgical facilities in the province be using the same checklist?
A. All AHS sites will be provided with the AHS Safe Surgery Checklist but sites should ensure the
checklist is suitable for their particular environment to enable successful implementation. The
checklist can be adjusted, based on predetermined modification criteria (see Section 3.1), to suit the
needs of the sites to help ensure the safety of their patients, the flow of surgical procedures, and the
commitment of the entire surgical team.
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Q. Who should be in charge of leading the surgical checklist in the OR/surgical suite?
A. AHS recommends that the sites or surgical groups determine who should be leading the surgical
checklist prior to implementation. This decision should be based on the individual particulars of the
site environment. Sites participating with the piloting of the checklist in Alberta had different
successes with different approaches. Some groups felt the best success came with the surgeon
leading the entire checklist. Other pilot groups assigned each section of the checklist to different
groups, while others pre-identified specific portions of each section by function (i.e. the
anesthesiologist lead all portions relating to anesthesia). The responsibility for the checklist lies with
every member of the OR team, including surgeons, anesthesiologists, nurses, technicians and any
other OR staff members.
Q. What procedures do you use the AHS Safe Surgery Checklist for?
A. AHS has defined surgery very broadly to include any procedure involving an incision, excision,
manipulation or suturing of tissue requiring regional, general or monitored anesthesia by an
anesthesiologist or anesthetist. The surgical checklist is not limited to only formal operating room
settings and can be adapted to any procedure room at any AHS site to improve patient safety. It is
up to the sites to evaluate which procedures the checklist is suitable for. The WHO recommends the
surgical checklist be adapted in any environment and setting where ‘surgical’ procedures are being
completed, including and not limited to emergency department procedure rooms, birth centers
performing c-sections, radiology departments performing invasive radiology procedures, etc.
Q. What is the target date for implementation?
A. AHS is asking sites to introduce the AHS Safe Surgery Checklist to all surgical groups within
existing functional operating room settings by April 2010. The use of a surgical checklist will become
an Accreditation Canada requirement for all sites in Canada going through accreditation based on
standards dated as of 2011.
Q. Is there support for surgical groups implementing the AHS Safe Surgery Checklist?
A. YES, AHS will be establishing a support system for individual sites during the implementation
phase. There will be Quality and Operational staff that will be identified within zones (see Appendix III)
to mentor groups, provide support to answer questions and communicate issues to the provincial
steering committee for action.
Q. How will we know if implementing the AHS Safe Surgery Checklist has made a difference?
A. AHS is developing a measurement dashboard to support the implementation and sustainability of
the surgical checklist which will measure usage of the checklist and the impact on outcome to
patients. The measurement plan will be communicated to all AHS sites when it is completed. The
plan will be relevant to sites using either paper OR charting or electronic patient management
systems. Outcome measures are being developed with input by healthcare professionals from
around the province to ensure appropriate metrics are in place so surgical teams understand the
impact of the checklist on improving the safety of patients undergoing surgical procedures.
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2.0 Guidelines for Use of the AHS Safe Surgery Checklist
The following are a set of guidelines developed to assist AHS sites in determining how to use the
surgical checklist. For full discussion of the rationale and use of each item on the AHS Safe Surgery
Checklist, please refer to Appendix II.
AHS sites are advised to review the WHO Safe Surgery website for additional support in
understanding how to use the checklist. Alternatively, the Institute for Healthcare Improvement (IHI)
and the Canadian Patient Safety Institute (CPSI) also have educational and supportive material
(including demonstration videos) that may be beneficial to AHS sites (website addresses listed
below).
http://www.who.int/patientsafety/safesurgery/en/
http://www.ihi.org/IHI/Programs/ImprovementMap/WHOSurgicalSafetyChecklist.htm
http://www.patientsafetyinstitute.ca/English/toolsResources/sssl/Pages/default.aspx
2.1 General Guidelines
1. The AHS Safe Surgery Checklist is intended as a communication tool that requires
participation of ALL members of the surgical team.
2. AHS strongly urges ALL members of surgical team be present for all three (3) portions of
the checklist (Briefing, Time Out and Debriefing). While it may not always be possible for all
team members to be available to participate in the Briefing, all members of the surgical
team MUST be present for the Time Out and Debriefing portions. Team members who are
not able to attend the Briefing must pre-arrange to discuss the details of Briefing section
with the other members of the surgical team prior to the case.
3. AHS urges AHS surgical teams to include (when appropriate) patients (or family members)
for the Briefing portion of the checklist.
4. Surgical teams should pilot the checklist using established quality improvement approaches
(e.g. PDSA) before full implementation to identify a process that ensures the smooth and
efficient running of the checklist.
5. Surgical teams / sites should pre-assign the role of leading the safety checklist to (a)
member(s) of the Surgical Team.
a.
The WHO suggests that a single person be made responsible for performing the
safety checklist.
b.
Some AHS checklist pilot sites found it preferable to designate the lead of the
checklist as follows:
Briefing – Anesthesia
Time Out – Surgeons
De-Briefing – Nursing
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c.
Alternatively, other sites have designated the lead for the checklist according to
subsections of checklist appropriate to their function (i.e. anesthesiologist will
verbally review all portions of the checklist related to anesthesiology, etc).
6. The AHS Safe Surgery Checklist is designed to ensure the BOLD headings and bullet
points are communicated verbally by the individual leading the checklist (or portion of) and
verbally confirmed with the appropriate team member(s) to ensure that the key actions have
been completed. The non-bold bullet points serve as triggers for discussion.
7. It is appropriate for the team member leading the checklist to skip a heading or bullet point
on the checklist ONLY if it is NOT applicable to the patient or procedure.
8. Each individual section of the checklist should not take more than 1 minute to complete
unless issues have been identified which require action. Ideally the checklist should add no
more than 2 minutes of time in total to the surgical procedure.
9. Briefing Section should occur prior to induction of anesthesia (either in the holding area,
operating theatre or procedure room).
10. Time Out Section should occur after induction and just prior to commencement of procedure
(before skin incision).
11. Debriefing Section can occur simultaneously with wound closure, but must occur prior to the
surgeon leaving the room.
2.2 Impact of the Safe Surgery Checklist for High Volume Cases
Some AHS sites that participated in the provincial pilot of the surgical checklist identified some issues
with the flow of cases particularly when using the surgical checklist with high volume cases. Other
sites did not experience any issues or negative impact on individual cases when implementing and
integrating the checklist with any surgical procedure or group and found the checklist could be easily
adapted to all groups.
AHS encourages sites to review the implementation strategy with the understanding that the surgical
checklist should not negatively impact operational efficiency or impede the flow of surgical cases and
procedures. AHS sites are encouraged to consult with the resources identified to support
implementation if any site or surgical group finds the surgical checklist does not easily adapt to their
situation. The Zone Operational leads and the Clinical Quality Support Consultants (see Appendix III)
supporting this initiative through the Implementation Working Group are able to provide sites with
insight and draw on the experiences of individuals from AHS that participated in the pilot phase.
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3.0 Modifying the Checklist
AHS has approved a modified version of the WHO Surgical Safety Checklist for use across the
province. The checklist, while intended to be universally applicable, may not be a perfect fit for all
AHS sites. AHS sites or surgical groups may choose to use the AHS Safe Surgery Checklist or
modify it to meet the needs of their unique procedures. Groups must ensure modifications are
consistent with the AHS Guidelines (see Section 2.0) and the WHO 10 Essential Objectives for Safe
Surgery (see Section 1.1).
3.1 Guidelines for Modification of AHS Safe Surgery Checklist
1. Modification must include three key stages for communication by the surgical team (i.e.
briefing, time out and debriefing)
2. Sites may add additional items that are deemed essential; however, removal of any checklist
item (heading or bullet point) is not an option with the following exceptions:
Optional Briefing Checklist Items:
a. “NPO status” bullet point
b. “Relevant and special equipment confirmed and in room” heading
c. “Relevant tests completed and checked” heading
d. Laboratory bullet point
e. Radiology bullet point
f. Pregnancy bullet point
g. Crossmatch (Type and Screen) bullet
(Note: Sites are NOT permitted to remove ‘Risk of Blood Loss” bullet point in the
Time Out section)
Optional Time Out Checklist Items:
h. “Procedure duration” bullet point
i. “Thromboprophylaxis (VTE) ordered” bullet point (for pediatric procedures
ONLY)
j. “Anticoagulant” bullet point
k. “Mechanical” bullet point
3. Sites are free to modify the following aspects of the checklist:
a. Color
b. Formatting
c. Language / terminology
d. Move individual checklist items to another section of the checklist (i.e. move
“Essential imaging displayed” to Briefing Section, etc) to correspond to current
surgical routines
e. Duplicate essential items in multiple sections
f. Add designation of Surgical lead
g. Separate and color code the checklist according to Surgical lead
4. The process of modification at a site must involve members of the surgical team (surgeons,
anesthesiologists, nurses and other members of the surgical team), and the resulting
checklist trialed in simulated and real-life situations in order to ensure its functionality.
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3.1.1 WHO Recommendation for Modifying the Surgical Checklist
The WHO has outlined the following guidelines to assist sites in evaluating and modifying
the surgical checklist to ensure safety steps inspire effective change and comply with each
element key surgical objective for safe surgery.
Adapted from: WHO Guidelines for Safe Surgery 2009.
Focused
•
The Checklist should strive to be concise, addressing the most critical issues not
adequately checked by other safety mechanisms.
•
Five to nine items in each section of Checklist is ideal.
Brief
•
The Checklist should take no more than a minute for each section to complete.
•
A more exhaustive Checklist will impact the flow of care.
Actionable
•
Every item on the Checklist must be linked to a specific, unambiguous action.
Verbal
• The function of the Checklist is to promote and guide a verbal interaction among
team members which is critical to its success.
Collaborative
•
Any effort to modify the Checklist should be in collaboration with representatives from
groups who might be involved in using it.
•
Actively seeking input from nurses, anesthesiologists, surgeons and others is important in
creating the feeling of “ownership” which is central to adoption and permanent practice
change.
Tested
•
Prior to any rollout of a modified Checklist, it should be tested in a limited setting.
•
The real-time feedback of clinicians is essential to the successful development and
implementation.
•
Important to test using “simulation” with may involve simply running through the Checklist
with team members sitting around a table.
•
Suggest using the Checklist for a single day by a single operating team and collecting
feedback to ensure an easy fit in the flow for the operating room.
•
Plan the wider implementation to all groups.
Integrated
• Many of the processes that are part of the WHO Checklist are part of the current
processes for ensuring safe surgical outcomes.
• The major additions to existing routines involve the integration of team communication,
briefings, and debriefings which are of critical importance and should not be removed from
the Checklist.
• Teams may consider adding other safety checks for specific procedures, particularly if
they are part of a routine process established in the facility
o availability of essential implants (such as mesh or a prosthetic),
o specific equipment needs
o critical preoperative biopsy results
AHS Safe Surgery Checklist Manual - 13
4.0 Implementation of the AHS Safe Surgery Checklist
The following section provides suggestions and recommendations for implementing the checklist with
different surgical groups at AHS sites, understanding that different practice settings will adapt the use
and performance of the surgical checklist to their own circumstance.
AHS recommends that each surgical team practice with the checklist to ensure the integration can
easily be adapted into everyday practice. The ultimate goal of the AHS Safe Surgery Checklist is to
help ensure that teams consistently follow a few critical safety steps and thereby minimize the most
common and avoidable risks that endanger the lives and well-being of surgical patients.
4.1 Recommended Process for Implementing the AHS Safe Surgery
Checklist
1. Identify Champions
• Identify a surgical, anesthesia, and nursing lead at each site to develop a strategic
planned approach for implementing the surgical checklist.
2. Meet with Hospital/Site Leaders
• Ensure support for implementation and discuss how the hospital/site leadership can assist
in promoting the checklist.
3. Start to Communicate the Message
• Develop a communication strategy.
• Start the communication by introducing the surgical checklist to all members of the
surgical team (surgeons, anesthesiologist, nursing, and other OR staff members).
o Recommend presentation of the surgical checklist by the surgical lead at site /
regional surgical meetings.
4. Identify a Surgical Group
• Identify and approach a surgical group most likely to be supportive of the surgical
checklist and would be willing to be the first to use the checklist.
5. Involve Site Clinical Quality Support Consultants
• Clinical Quality Support staff can provide surgical groups with guidance in strategic
approaches for implementation, measurement of quality improvement, piloting strategies,
etc.
6. Build a Team
• Establish a site (or service) project team with representation of all clinical team members
involved in surgical procedures.
• Identify a core group of people who are enthusiastic about the checklist while trying to
involve at least one member from each of the clinical disciplines.
• At the early stages of planning and implementation, work with those who are interested
and willing to participate, rather than trying to change the most resistant people.
• Set up regular meeting schedule for the team.
7. Review Support Material
• Video links and support material to understand how to use the checklist appropriately are
available at the following websites:
o http://www.who.int/patientsafety/safesurgery/en/
o
http://www.ihi.org/IHI/Programs/ImprovementMap/WHOSurgicalSafetyChecklist.htm
o
http://www.patientsafetyinstitute.ca/English/toolsResources/sssl/Pages/default.aspx
AHS Safe Surgery Checklist Manual - 14
8. Adopt a Quality Improvement Strategy That Will Work for the Site / Service
i. Start Small, Then Expand
• Start with a single operating room, department and / or surgeon.
o It was noted by sites participating in the WHO study that sites that
tried to implement the checklist in multiple operating rooms
simultaneously faced the most resistance and had the most trouble
convincing staff to use the checklist effectively.
o Consider using an approach, such as PDSA cycles, that will allow
the team to test the suggested changes and the impact on current
processes, before fully implementing the checklist.
ii. “Test Drive” the Checklist
• Trial the checklist in one operating room with one team, then move forward
after problems have been addressed.
o Some provincial sites involved in the original pilot phase found it
useful to:
ƒ Set a targeted ‘“go-live” date.
ƒ Roll out / introduce the checklist to different surgical groups
for a week of “practice runs”
ƒ Practice with a new surgical group each week.
ƒ Address comments or concerns at the project team level.
o As you spread the implementation of the checklist, use the learning
from previous teams to assist new teams with implementation.
iii. Implement After a Practice Run
9. Monitor Implementation Progress
• The Implementation Working Group will support sites / surgical groups in monitoring the
progress of the implementation.
10. Measure Usage and Impact on Outcome
• Measurement of the usage and outcome of implementation will be developed by the AHS
Safe Surgery Checklist Steering Committee and will be communicated to sites when
available.
11. Communicate the Progress of the Implementation to All Surgical Members
12. Celebrate and Reward Successes
4.2 Support for Implementing the AHS Safe Surgery Checklist
AHS will be supporting AHS sites with implementation of the AHS Safe Surgery Checklist. An
Implementation Working Group has been established to provide direct support for sites in each of the
five (5) provincial zones (see Appendix III). Each Zone will have an operational representative and a
Clinical Quality Support (CQS) Consultant representative.
These individuals will provide direct
support and guidance for sites. The Zone operational and CQS representatives are members of the
provincial Working Group, which act as the communication link for sites to the Provincial Steering
Committee and report on the progress of the implementation. The working group will have available
to them the knowledge that was developed at AHS during the pilot phase and involve individuals that
have supported and assisted in the development of the AHS Safe Surgery Checklist and this manual.
CPSI and Safer Healthcare Now (SHN) have announced ‘Checklist Action Series’ and workshops to
support Canadian sites with the implementation of the surgical checklist. AHS supports and
AHS Safe Surgery Checklist Manual - 15
recommends sites take advantage of the opportunity to participate (link for information and
registration details can be found on the CPSI website).
http://www.patientsafetyinstitute.ca/English/toolsResources/sssl/Pages/default.aspx
AHS sites are advised to review the WHO Safe Surgery, the Institute for Healthcare Improvement
(IHI), and the Canadian Patient Safety Institutes (CPSI) website for support in understanding how to
implement the checklist as part of their routine. Each of the websites listed below have educational
and supportive material (including demonstration videos) that can assist sites in understanding how
to adopt and use the checklist appropriately.
http://www.who.int/patientsafety/safesurgery/en/
http://www.ihi.org/IHI/Programs/ImprovementMap/WHOSurgicalSafetyChecklist.htm
http://www.patientsafetyinstitute.ca/English/toolsResources/sssl/Pages/default.aspx
4.3 Quality Improvement Strategies for Implementation
AHS surgical teams / sites should use a quality improvement approach to pilot the checklist and test
the impact on current operational processes before full implementation. The use of quality
improvement techniques such as PDSA cycles to test suggested changes to existing OR processes
are very useful before surgical groups fully implementing the checklist. They enable teams to
determine the impact the change has on efficiency and flow of procedures, and ensure the quality of
care and patient safety is maintained. Clinical Quality Support staff are available to provide support
to any site or surgical group regarding methods for piloting improvement initiatives such as the
surgical checklist.
4.4 Communication Strategies
The development of a communication strategy by sites is critical to the success of any
implementation and change management process. Sites must develop methods to effectively
promote the surgical checklist to all the key stakeholders (patients, surgeons, anesthesiologist, OR
staff, hospital staff, hospital leadership, etc). The Implementation Working Group (see Appendix III)
has tools and support that can be made available to sites upon request that may assist in effectively
communication and message to all. The communication strategy should be included as part of the
implementation plan for each site.
•
•
Templates for posters that can be used by sites to promote the use of the surgical checklist
can be obtained from the Operational Working Group (see Appendix III) and an example will be
included as part Implementation Package.
Communication strategies and material can be found at websites listed below:
o http://www.who.int/patientsafety/safesurgery/en/
o
http://www.ihi.org/IHI/Programs/ImprovementMap/WHOSurgicalSafetyChecklist.htm
o
http://www.patientsafetyinstitute.ca/English/toolsResources/sssl/Pages/default.aspx
AHS Safe Surgery Checklist Manual - 16
Additional support will be provided to sites through the Implementation Working Group (see Appendix
III) which can share communication tools and power point presentations that were used by other sites
around the province to promote the surgical checklist.
Communication strategies used by AHS pilot sites included:
•
Posters in the operating rooms.
•
Presentation by surgical / anesthesiology site leads at medical rounds.
•
Presentation at site based quality and safety committees.
•
Presentations at OR staff meetings.
•
Email reminders to members of the surgical team before the start of the trial / pilot.
•
Posting and sharing the New England Journal of Medicine article (see Appendix I).
•
Memos from hospital and medical leaders supporting and endorsing the surgical
checklist.
4.5 Key Communication Messages to Assist with Implementation and
Engagement
1. Each individual portion of the AHS Safe Surgery Checklist has been included based on
clinical evidence or expert opinion gathered from around the province. The inclusions of
specific portions of the checklist have been incorporated to reduce the likelihood of serious,
avoidable surgical harm.
2. The AHS Safe Surgery Checklist was designed for simplicity and brevity. Many of these steps
are already accepted as routine practice in facilities around the world but the checklist brings
all of them together in a forum of open communication.
3. Successful implementation requires adapting the checklist to local routines and expectations.
4. The AHS Safe Surgery Checklist is meant to be used as a communication tool to provide
teams with a simple efficient set of high priority checks for improving communication which
will help to ensure that the safety of the patient is a top priority in every single operation that is
done.
4.6 Physician Engagement Strategies
Physician engagement is a critical aspect and key success factor in the implementing of any
improvement initiative in healthcare. The surgical checklist must be viewed by physicians as adding
value to patient care and improving the outcome for their surgical patients. The key to the success of
the implementation lies with ensuring that physicians at each site take ownership, are consulted and
are involved with all aspects of the review and implementation process. Their involvement and
participation on site based implementation teams is essential. Some physicians may view the
checklist as a nursing tool and project team should ensure surgeons and anesthesiologists
understand that it is a surgical safety tool that requires the involvement and active participation of all
members of the surgical team.
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Names of physician that are willing to act as mentors to other physicians are available through the
Implementation Working Group (see Appendix III. These are surgeons and anesthesiologists that
were involved in the piloting of the checklist and the design of AHS Safe Surgery Checklist that are
willing to discuss the checklist and their experience using the checklist with other physicians.
4.7 Measurement
AHS has established a Measurement Working Group to develop a provincial measurement plan
which will provide long term review and reporting in compliance with the new Accreditation Canada
Surgical Checklist ROP standard. The AHS Safe Surgery Checklist provincial steering committee will
ensure the measurement plan is relevant to sites using either paper OR charting or electronic patient
management systems. The plan will include identification of appropriate metrics for both usage and
outcome, and ensure reporting to key local, zone and provincial stakeholders.
There are two separate stages to implementation; the first stage is the actual introduction and
implementation of the checklist at the sites. There are plans for a measurement piece that will
provide sites and the Steering Committee with feedback on the progress of the implementation. The
second phase of implementation is the long term provincial Safe Surgery Checklist measurement
plan which the Steering Committee will implement after development and careful review with
surgeons, anesthesiologist and nurses from around the province. This measurement plan will be
communicated to all sites prior to the rollout.
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APPENDIX I
AHS Safe Surgery Checklist
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APPENDIX II
Guidelines for Use of the AHS Safe Surgery Checklist (detailed)
I. Before Induction of Anesthesia- BRIEFING
These safety checks are to be completed before induction of anesthesia in order to confirm that
key safety procedures have been completed and reviewed before proceeding. AHS strongly urges
that all members of the surgical team make every effort to attend and participate at each of the three
portions of the surgical checklist. The individual leading the checklist may complete this section all at
once or sequentially, depending on the flow of preparation for anesthesia. The details for each of the
safety steps are as follows:
1. Patient (family member) and / or Surgical Team Members have Verbally Confirmed
The individual leading the checklist for this section verbally confirms:
• patient’s identity,
• procedure,
• site, side or level,
• consent for surgery has been given.
While it may seem repetitive, this step is essential for ensuring that the team does not operate on the
wrong patient, wrong site or perform the wrong procedure on the patient. When confirmation by the
patient is impossible, such as in the case of children or incapacitated patients, a guardian or family
member can assume this role. If a guardian or family member is not available, the surgical team can
confirm that they are all in agreement to the items covered prior to proceeding.
It is also important at this time to verbally confirm if the patient has any known allergies and what the
typical reaction to the allergen is for the patient.
NPO Status has been placed on the checklist in this section – It is the only optional item in this
section and can be removed during modification of the checklist if it is deemed non-essential
information to your local process.
2. Special Precautions
The individual leading the checklist also completes this next step in the presence of the patient or
family member by asking if the patient has any special cautions that may impact the outcome of the
procedure. For example, does the patient know of issues with malignant hyperthermia, latex
allergies, requires isolation precautions, etc.
3. Weight (Kg) Recorded on Chart
Many dosages are based on weight for pediatric and adult procedures and it is essential that
confirmation of the weight has been recorded on the chart.
4. Anesthesia Safety and Equipment Check Completed
The individual leading the checklist completes this next step by asking the anesthesiologist to verify
completion of the anesthesia safety check which may involve formal inspection of all anesthetic
equipment, breathing circuit, medications and review of the patient’s anesthetic risk. The anesthesia
team should complete the ABCDE’s (Airway equipment, Breathing system - including oxygen and
inhalational agents, suction, drugs and devices and emergency medications, equipment).
AHS Safe Surgery Checklist Manual - 20
5. Difficult Airway/Aspiration Risk
The individual leading the checklist should verbally confirm that the anesthesia team has objectively
assessed whether the patient has a difficult airway. Death from airway loss during anesthesia is still a
common disaster globally but is preventable with appropriate planning. If the airway evaluation
indicates a high risk for a difficult airway, the anesthesia team must prepare against any potential
issues including (but not limited to): adjusting the approach to anesthesia (for example, using a
regional anesthetic, if possible); and having emergency equipment accessible. A capable assistant—
whether a second anesthesiologist, the surgeon, or a nursing team member—should be physically
present to help with induction of anesthesia. The risk of aspiration should also be evaluated as part
of the airway assessment. If the patient has symptomatic active reflux or a full stomach, the
anesthesiologist must prepare for the possibility of aspiration. The risk can be reduced by modifying
the anesthesia plan, for example using rapid induction techniques and enlisting the help of an
assistant to provide pressure during induction. For a patient recognized as having a difficult airway or
being at risk for aspiration, induction of anesthesia should begin only when the anesthesiologist
confirms that he or she has adequate equipment and assistance present at the bedside.
6. Patient Positioning and Support Confirmed
To prevent delays, the surgeon must review their plan for patient positioning and support
requirements for the team. If the surgeon is unable to attend the Briefing portion of the checklist,
they must ensure that a review occurs with the attending anesthesiologist prior to the team briefing.
7. Relevant Special Equipment Confirmed and In Room
The individual leading the checklist should verbally review the need for any relevant and special
equipment not normally found in the theatre. This may include but is not limited to confirmation that
prosthesis, warming devices or loaner instruments are checked and confirmed. This box is optional
on the checklist and may be removed if not applicable to local procedures.
8. Relevant Tests completed and checked
The individual leading the checklist should verbally confirm that someone has reviewed and
confirmed the completion and availability of all relevant laboratory and radiology procedures. This
may include confirmation of pregnancy test for female patients, completion of a type and screen
and/or crossmatch to ensure that blood products can be made available if required. Confirmation of
requested radiology should also ensure availability of all essential imaging during the procedure. This
box is optional and may be removed during modification if not applicable to local practice.
A decision was made to move the discussion of blood loss to the time out section to avoid increasing
the stress to the patient and/or family members present. It was decided however, that it was
important to have the confirmation of the crossmatch in the briefing section to save time if it had
indeed been missed.
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II. Before skin incision- TIME OUT
Before making the first surgical incision, a momentary pause should be taken by the team in order to
confirm that several essential safety checks are undertaken. These checks must involve all team
members.
9. All Team Members Have Introduced Themselves by Name and Role
Operating room team members may change frequently. Effective management of high risk situations
requires that all team members understand who each member is and their roles and capabilities. A
simple introduction can achieve this. The individual leading the checklist should ask each person in
the room to introduce him or herself by name and role.
Teams already familiar with each other can confirm that everyone has been introduced. If additional
staff have rotated into the operating room since the last operation, they should introduce themselves.
This introduction should include students or other personnel.
10. Surgeon, Anesthesiologist, and Nurse Have Verbally Confirmed: Patient, Procedure,
Site
The individual leading the checklist will request all team members to stop and verbally reconfirm:
• name of the patient,
• procedure to be performed,
• site of surgery
For example, the circulating nurse might announce, “Before we make the skin incision does
everyone agree that this is patient X, undergoing a right inguinal hernia repair?” The anesthesiologist,
surgeon and circulating nurse should explicitly and individually confirm agreement.
11. Anticipated Critical Events
To ensure communication of critical patient issues, the individual leading the checklist leads a swift
discussion among the surgeon, anesthesia and nursing staff of critical dangers and operative plans.
The order of discussion does not matter, but each clinical discipline should provide information and
communicate concerns.
a. Surgeon Review
The surgeon’s review should involve the following:
• A review of the critical steps associated with the procedure that may result in
injury or risk of morbidity. This is also a chance to review steps that might require
special equipment, implants or preparations.
• Duration of procedure is to ensure that all team members understand the
expected length of the procedure which may be longer (or shorter) than expected
due to issues unique to the procedure or patient.
• A review of the Risk of >500 mL blood loss (7 mL/Kg in children) is one of the
WHO 10 essential objectives for safe surgery and is a requirement for all surgical
checklist.
Large volume blood loss is among the most common and important dangers for
surgical patients, with risk of hypovolemic shock escalating when blood loss
exceeds 500 mL (7 mL/Kg in children). Adequate preparation and resuscitation
may mitigate consequences considerably. Surgeons may not consistently
communicate the risk of blood loss to anesthesia and nursing staff. Therefore, if
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the specific risk of major blood loss associated with the patient or the procedure is
unknown or unclear, the surgeon can discuss the situation with the team prior to
commencement.
b. Anesthesiologist Review
The anesthesiologist’s review should involve the following:
• Are there any patient-specific concerns?
• Is there adequate intravenous access and fluid planned?
If there is a significant risk of a greater than 500 mL blood loss, it is highly
recommended that at least two large bore intravenous lines or a central venous
catheter be placed prior to skin incision. In addition, the team should confirm the
availability of fluids or blood.
c. Nursing Review
The nurse’s review should involve the following:
• Are there any issues relating to sterility
• Are there any issues relating to equipment
The scrub nurse or technologist who sets out the equipment for the case should
verbally confirm that sterilization was performed and that, for heat-sterilized
instruments, a sterility indicator has verified successful sterilization. Any
discrepancy between the expected and the actual sterility indicator results should
be reported to all team members and addressed before incision. This is also an
opportunity to discuss any problems with equipment and other preparations for
surgery.
During routine procedures or those with which the entire team is familiar, the surgeon can simply
state, “This is a routine case of X duration” and then ask the anesthesiologist and nurse if they have
any special concerns. For many procedures that do not generally entail particularly critical risks or
concerns anesthesiologist and nurse can also simply say, “I have no special concern regarding this
case.”
12. Applicable Medication Concerns
• Antibiotic Prophylaxis Given Within Last 60 Minutes
This is another of the 10 WHO essential objectives for safe surgery. Despite strong
evidence and wide consensus that antibiotic prophylaxis against wound infections is
most effective if serum and/or tissue levels of antibiotic are achieved, surgical teams
are inconsistent about administering antibiotics within one hour prior to incision.
To reduce surgical infection risk, the individual leading the checklist will ask out loud
whether prophylactic antibiotics were given during the previous 60 minutes. The team
member responsible for administering antibiotics (typically the anesthesiologist) should
verbally confirm if prophylactic antibiotics have been administered and if not it should
be administered prior to incision. If prophylactic antibiotics have been administered
longer than 60 minutes prior, the team should consider re-dosing the patient.
A simple verbal “not applicable” announcement will suffice if prophylactic antibiotics are
not considered appropriate.
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•
Thromboprophylaxis (VTE) Ordered
VTE is one of the most common and preventable complications of hospitalization. If
VTE thromboprophylaxis is not instituted, then 10 to 40% of general surgery patients
and 40 to 60% of hip surgery patients will develop VTE. This is not one of the WHO 10
essential objectives for safe surgery, but is listed as a recommended addition that a
number of countries have included in their checklist. The medical members of the
Surgical Checklist Steering Committee felt strongly that this must be part of the AHS
Safe Surgery Checklist is not optional.
How-to Guide: Prevention of Venous Thromboembolism. Safer Healthcare Now! Campaign May
2008.
http://www.saferhealthcarenow.ca/EN/Interventions/vte/Documents/VTE%20Getting%20Started%20Kit.pdf
•
Other Specific Medication Concerns
This provides the team to highlight any additional medication related concerns.
13. Essential Imaging Displayed
Imaging is critical to ensure proper planning and conduct of many operations and is one reason
for delays. Before skin incision, the individual leading the checklist should ask the surgeon if
imaging is needed for the case and confirmation that essential imaging is available and
prominently displayed. If imaging is needed but not available, it should be obtained and the
surgeon can decide whether to proceed without the imaging.
14. Any Other Questions or Concerns Before Proceeding
This provides all members of the team the opportunity to voice any concerns prior to
commencement.
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III. Before Patient Leaves Operating Room- DEBRIEFING
These safety checks should be completed before removing the patient from the operating room. The
aim is to facilitate the transfer of important information to the care teams responsible for the patient
after surgery. The checks can be initiated by the circulating nurse, surgeon or anesthesiologist and
should be accomplished before the surgeon has left the room. It can coincide with wound closure.
15. Surgical Team Have Verbally Confirmed
• The Name of the Procedure
Since the procedure may have changed or expanded during the course of an operation,
the individual leading the checklist should confirm with the surgeon and the team exactly
what procedure was done. This can be done as a question, “What procedure was
performed?” or as a confirmation, “We performed X procedure, correct?”
• Applicable Sponge and Instrument Counts
Retained instruments, sponges and needles are uncommon but persistent and potential
errors that may result in serious harm to the patient. The scrub or circulating nurse should
therefore verbally confirm the completeness of final sponge and needle counts. In cases
with an open cavity, instrument counts should also be confirmed to be complete. If counts
are not appropriately reconciled, the team should be alerted so that appropriate steps can
be taken (such as examining the drapes, garbage and wound or, if need be, obtaining
radiographic images).
• Specimen Labeling and Handling
Incorrect labeling of pathological specimens is potentially disastrous for a patient and has
been shown to be a frequent source of errors. The scrub or circulating nurse should
confirm the correct labeling of any pathological specimen obtained during the procedure by
reading out loud the patient’s name, the specimen description and any orienting marks.
• Whether There Are Any Equipment Problems to be Addressed
Equipment problems are universal in operating rooms. Identifying the sources of
instruments or equipment failure is important in preventing devices from being recycled
back into the room. The individual leading the checklist should ensure that equipment
problems arising during a case are identified by the team.
16. Surgical Team Has Reviewed the Recovery Plan
The surgeon, anesthesiologist and nurse should review the post-operative recovery and
management plan, focusing in particular on intraoperative or anesthetic issues that might affect the
patient. Events that present a specific risk to the patient during recovery may not always be evident
to all members of the surgical and recovery team. The aim of this step is the efficient and
appropriate transfer of critical information to the entire team so the following issues should be
reviewed:
• Patient Disposition
• Analgesia
• O2 Needs for Transfer
• Specific Concerns
With this final step, the AHS Checklist is completed.
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APPENDIX III
AHS Implementation Working Group Membership List
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APPENDIX IV
Reference Article I
Haynes AB, et al. A Surgical Safety Checklist to Reduce Morbidity and Mortality in a Global
Population. N. Engl J Med, 2009; 360; 491-9.
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