Surgical Safety Checklist: The Use of a Checklist in an Operation Room - Essay Example

? The use of a checklist in an operation room Nurses face many challenges in the operating room. Medical errors in the OR occur most of the time mostly as a result of a communication breakdown among the caregivers. Medical errors are avoidable and require the ongoing staff t be educated. Mrs. Susan Will, the obstetric patient safety nurse, asked a CNS student to create an observation tool to be tested in the labor room at Johns Hopkins Hospital SekiahZayied tower.The main aim of this tool was to assess adherence to an OR checklist. This study evaluated the use of the WHO Surgical Safety Checklist, that impact of operating room briefings on coordination of care. Data were prospectively collected in the cesarean section OR with C’ section patients and the outcome of eleven cases of patients undergoing this operation was gathered and analyzed after direct observation of the OR checklist was applied . Findings suggested that in the general operation room, the checklist was used. In contrast, in the operation room of the labor department,the checklist tool was not used . To increase the probability of achieving patient safety and minimal errors when implementing the use of checklist tool, such as World Health Organization’s Surgical Safety Checklist, the integration between OR members of the different professions and teamwork must be enhanced. Key words: checklist, WHO surgical safety checklist. . Introduction and statement of the problem The nursing leadership needed to evaluate the possibility of educating all the healthcare professionals on the use of a safety checklist and to gain an increased awareness of the challenges and solutions connect with such an effort. The obstetric patient safety CNS at Johns Hopkins Hospital wanted to study the reasons why the OR checklist was not being used. They questioned whether it was due to inexperience, lack of communication, time constraints or lack of competence by the team members. The study was fueled by the information provided saying that most hospitals do not use the checklist (Ohlson, 2008). The ultimate goal of the use of the checklist is to reduce the frequency of human mistake in the completion of a complex, multistep task like C” section. It also helps to improve communication and guarantee safe and standardized procedure, by this means minimizing error. Overcoming barrier to implementation of the checklist in the OR was growing. Lack of using the checklist therefore led to the increase of the above mentioned defects. The organization started testing the checklist over a year ago and they provided information for all caregivers teams regarding their attitudes toward the use of a surgical checklist. Still not all team members related that they were aware of the checklist and its purpose and they were not using the resource. The use of the checklist did not become part of the culture of the unit. Some team members were / and are resistant to checklists. Support for use of apre-operative checklist to increase patient safety has been described. In a study by Nilsson, Lindbergt, Gupta &Vegfros (2010), staff awareness of the benefit of the use of a checklist and attitudes towards the use of a checklist improved after one year. Assessment Organizational need According to JHU nursing leadership, there was a need for all OB and OR team members know each other as the research supported that this would make people more willing to speak up if they perceived a certain problem during the case. The team members also needed to have a shared mental model regarding the scope of the case and the plan of care for the patient after the case. It was viewed that most nurses did not make good use of the checklist. The use of the checklist also goes a long way in helping the nurses remember to cover all the basics. This is because not everyone has the ability to memorize all that is required. The operating rooms are highly procedural environments that require surgical teams to be very meticulous (Hayes, 2012). Clinical problem and current approach According to the data gathered during the survey and also from the questionnaires, it was evident that the nurses and other medical personnel had been operating for years without the use of a checklist. The OR Process Committee had been workingtirelessly to improveinterprofessional communication in the OR and also provide staff with a tool that would help ensure that some basic standards of practice (not already included in the time-out) were outlined on a checklist. Historically, there have been some obstetrical sentinelevents resultedfrom a lack of communication in the OR. A follow-up action item was to create the role of the facilitator in the OR – so that for high acuity cases- there would be one team member who would oversee the communication in the OR – helping to ensure that all team members had a shared mental model such as a checklist to follow. A checklist is a very vital tool that if followed carefully, can help avert errors. The World Health Origination (WHO) has undertaken the first step to cover surgical safety both locally and globally. The leader of (Johns Hopkins Quality and safety research Group) (QSRG) Dr Peter Pronovost, created a draft of an infection preventionist (IP) Checklist for the Comprehensive Unit-based Safety Program (CUSP).Furthermore, the Operating rooms are extremely technical environments where presented teams are expected to synthesize, retain, and communicate large amounts of information ( Hayes, 2012). From this Point Mrs. Susan Will, (Patient safety of obstetric department) wanted to explain how specialcare is given in OR labor rooms . She also wanted to know why the checklist in the OR had been posted longago and no one applied it. The OB OR needs to address this issue to improve patient safety andreduce errors (Haynes, 2011). All circulating nurses who were assigned for each case were asked questions in this study. The surveywas constructed based of the OB OR needs.The checklist has 40 items to be testfocused briefing time out just prior to incision and post case sign out before surgeon leaves .The teams were applied in different rate based on different team awareness and initiation. Literature Review Before starting my project i conducted a literature review; Pub Med, Google scholar, Google Book CINHAL on the keywords: Checklist use in the operating room and Surgical Safety Checklist. In general, the literature suggested that the use of the checklists improved patient safety through effective teamwork. Other keywords that were used in the search includes; Differences in Nurse and Surgeon perceptions of teamwork and the surgical safety Checklist. The literature in general suggested that improvements in safety relationships among OR staff decreased postoperative morbidity and mortality following implementation of a checklist-based surgical safety intervention, the checklist Manifesto, and safe patients Smart hospital(Gawande, 2009). Applying the World Health Organization surgical safety checklist to obstetrics and gynecology , the condition of many patients has improved and their plight protected (Haynes,2011). Implementing a pre?operative checklist to increase patient safety has been the main objective of many hospital committees. The use of a WHO checklist was found out to be the best procedure (Gawande, 2009).The World health organization safety checklist (figure 3)Checklist was developed by an international group of experts gathered by the WHO with the goal of improving the safety of patients undergoing surgical operation around the globe (Hayes, 2012). Contributions from anesthesiologists, operating nurses, surgeons, patients and other professionals was used in the improvement of this tool. Both small and large scale clinical testing of the checklist has been performed culminating in a multi-site pilot study with results published in the New England Journal of Medicine in January 2009.The results from these studies showed that most health facilities do not make use of the checklist.The use of a WHO checklist isto assist the operating teams in reducing the number of medical errors that were observed in the study. The Checklist was introduced to be applied within any health care setting (Burbos,2011). “In 2008, an evidence-based review of practice to identify the common cause of patient harm in the perioperative period led to the development of the (WHO) surgical safety checklist.”(Burbos, N.Morris, E. 2011). Patient safety required tools to be followed not just memorize the steps. Furthermore, checklists appear to offer protection against such failures (Gawande, 2009). This means that the useof a checklist will offer improvement in the postoperative outcomes. Also,improved communication of teamwork could improve safety through the change of clinician attitude. Understanding the relationship between effective team work by communication and patient safety has been shown to have an impact on understanding the improvement of surgical safety checklist (Hayes, 2012).Furthermore, preoperative checklist briefings have brought down the number of communication failure,- advanced positive and collaborative team communication. It also reduced unexpected delays in the OR, decreased the frequency of the communication breakdown that lead to delays, and reduced intraoperative incidents (Carney, B., West, P., Neily, J., Mills, P. D., &Bagian, J. ,2010). The follow up on the implementation and use of this checklist was done a year later. Caregivers such as surgeons, anesthesiologists, operation and anesthetic nurses and nurse assistants interviewed on the outcome responded positively about the positive impact of the checklist use (Nilsson, L., Lindberget, O., Gupta, A., &Vegfors, M.,2010). According to Burbos (2011), the format and the design of the checklist has been evolving with time. Initially it was used by health professionals in the surgery room. After a period of time, these professionals went back to ignoring its use (Cherian,2007). This was until the WHO body made it mandatory for every health facility to use the checklist (Sexton, 2006). (Ervin,2005) insisted that the checklist should be adopted strictly as it ensures error management. “ In 2008, an evidence-based review of practice to identify the common cause of patient harm in the preoperative period led to the development of the (WHO) surgical safety checklist.” (Burbos,N. Morris, E.,2011). The safety of the patient required tools to be followed as memorizing alone was not reliable. Proper use of the checklist reduced the number of communication failures , advanced positive and collaborative team communication. It also reduced delays in the OR, decreased the frequency of communication breakdown that led to these delays and reduced intra-operative incidents ( Nilsson, 2010). Most healthcare professions however never make it a habit to always checklists (Gawande, 2010).(Martin 2011) healthcare professionals can adopt the use of the checklist by ensuring that they make it a habit to follow it. Conceptual Model “Studies of organizational process, context, and culture, whose research focus was the adoption, assimilation, androutinization of an innovation were looked into. Here, the exploration of an organization’s innovativeness concentrated on the “softer,” nonstructural aspects of its makeup, especially the prevailing culture and climate. This was notably in relation to leadership style, power balances, social relations, and attitudes toward risk taking.”(Greenhalgh, T., Robert, G., Macfarlane, F., Bate, P., &Kyriakidou, O. 2004, p.591).The evolution of the change OB OR setting stems from physician,nurses and anesthesia. Therefore, some examples are derived from an organizational development perspective whereas others are based on individual (team) behavioral models. For this reason, this checklist is divided 3 sub-categories: briefing time out (just prior to incision), case Alerts and post case sign out (before surgeon leaves room). Furthermore, the checklist should be part of the culture to help in reducing errors to none through applying the 40 items outlined in the checklist. The model is appropriate for this study as it helps assess the level to which healthcare professionals follow the checklist. As observed, circulating nurses are the ones who mainly follow the checklist. Other personnel should follow suit and work hand in hand with the nurses in using the checklist. Methodology/intervention I performed an observational study at Johns Hopkins Hospital SekiahZayied tower using 11 cases. By reviewing the literature on ways of applying checklist in the OR, improving team work, I went on to observe scheduled- cases of women receiving cesarean section and asked OB OR caregivers to answer the survey questions for content relevance of which they well completed. The observational survey was designed to determine whether caregivers used the checklist. Furthermore, checklist committee’s carrying out requirements were used to assess the obedience to each checkpoint. To evaluate the usage of OB OR checklist, I participated in the observation schedule to gather data regarding briefing time out and post case sign out. The surveywas reduced to 40 items which reduced into 10 boxes (figure 1).I documented each team’s performance and discussed this with the nurses. 13 observations were conducted of which were suitable for analysis.I calculated how many boxes were applied in each case to display the findings for the CNS safety nurse in charge of this study and for the patient safety committee. Team communication and coordination during the preoperative phase were observed and discussed with the CNS. Finding The response rate was less than 60% of those applied. There were various reasons for not applying this checklist in OB OR, depending on the views of the different teams. Some physicians’ behaviors were so confident that OB OR staffs knew them . This means that there was no need to waste time to introduce themselves to them.Others were irritated when the nurses asked them to apply the checklist. This was especially on the use of the box where the staff are to introduce themselves. Favorable team behavior, observable shared communication behavior that promotes safety, on the other hand significantly improved as a result of applying the checklist . Circulating nurses had the highest implementation of time out just prior to incision (100%), all count correct –team confirm(100%), implementation of record name on the white board(72%) , team member confirm start (54%),staff introduce themselves (45%),surgeon verbally confirm(45%), checkbox of anesthesia confirm box (45%) ,surgeon confirm specimen and culture (36%)sign-out anesthesia confirm box before leaving the room(0%) but takes place in the recovery room final checkbox of any team member can request a debriefing (0%). Surgeon, Circulatory Nurse, Baby nurse and anesthesia (Obstetrics Operation Room team) were observed in their performance by applying the checklist (figure.2). First box regarding (staff to introduce themselves) 5 out of 11 cases were applied, Second box regarding (staff to record their names on white board) 7 out of 11 cases were applied. Third box regarding (Timeout) was well done as no one missed. Fourth box regarding (Surgeon verbally confirms pertinent medical history) 5 out of 11 cases were applied while the fifth box (Anesthesia verbally confirm) 5 out of 11 cases were applied. The sixth box (team member: confirms surgery may start) 6 out of 11 cases were applied, seventh box (all counts correct-team confirm) 11 out of 11 cases were applied. Sign-out surgeon confirmed the procedure, known as surgical complication specimen, 6 out of 11 cases were applied., sign out. Anesthesia verbally confirms estimated blood loss, transfusion, etc one out of 11 cases were applied. Finally, in the debriefing section 0 out of 11 cases. Discussion According to Ervin (2005), clinical coaching for evidence based nursing practice (EBNP) should become part of a supportive practice environment for professional nursing. CNSs should be involved in helping others to develop the knowledge and skills needed to enhance the use of evidence in nursing practice within an organization.Implementation of the WHO safety checklist in the OB operation room –base quality development project was associated with a small increasein mean teamwork and safety (Carney,2010). Differing perception of implementing the checklist in the OB operation room was observed.Circulating nurse was represented as the leader in the OB OR and applied the easy methodto such as ticking the checklist. CNS should increase awareness in the OB OR team on the benefits of using the checklist. As an observer not from the unit I found nurses considering this and trying to apply the checklist (Calland, 2011). Describe relevant ethical and legal concerns In the nursing literature, I found a number of references to operational failures, reworks and workarounds and the implications for unsafe practices. Tucker and Spear (2006) in their cross sectional study of six US hospitals examining the frequency of work system failures, observed that nurses experience an average of 8.4 work system failures in an eight hour shift. The top five most frequent failures involve medications, supplies, staffing, orders and equipment. A checklist would go a long way in helping avert some of these failures. Confidentiality of the data should be upheld and only revealed to the relevant authorities. The staff members that were used in the study are to remain anonymous. Implications for education, practice and future research Implementation of the surgical safety checklist for reducing error should be made more aware and cooperation of OB teams via health educational programs. Team training, and circulatory nurse leader Video and audio tape should be made available so as to emphasize on the importance of the checklist. The healthcare professionals should be educated by the respective healthcare committees regularly that their primary objective is to ensure patient safety.WHO should also step in to ensure that health facilities follow the use of the checklist.They should therefore make good use of the checklist as it goes a long way in reducing errors and improving patient safety (Hayes, 2011). This will ensure that possible errors are always reduced to a minimum. “ The key is to focus on how nurses spend their time because it's has the actual amount of time that nurses spend directly with patients that affects patient outcomes” (Storfjell,et al, 2008,p.245). The role of the CNS is to ensure that the nurses are educated on the proper use of the checklist. They are in charge of the nursing unit in which they are placed and with their vast knowledge in the field of nursing should ensure that proper procedures are followed in the health facility. Proper procedures that are to be followed include the use of the checklist. The WHO body should ensure that all CNS meets the required qualifications so as to ensure smooth running of the health facility. They also assist in collaboration. They enhance teamwork in the health facility where all health professionals work hand in hand. CNS is also available for consultation whenever one has a problem. In general they assist in the overall clinical and professional leadership. They conduct research on ways of improving the overall condition of patient safety, nursing personnel and the health care system as a whole. Acknowledgements Thankful and grateful to Mrs. Susan Will, and Mrs. Carey for the overall support and guidance throughout the whole project. References Burbos, N., & Morris, E. 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