A ‘paperless’ wall-mounted surgical safety checklist with
migrated leadership can improve compliance and team
engagement (2018)
JOURNAL
Submitted by:
Tamayo, Teanu Jose G. BSN-III D4
In partial Fulfillment of requirement
In CN 109: Duty
Submitted to:
Caluza, Alfrado G. RN, MPH
June 27, 2018
Supporting articles:
Leadership and Management Roles: Challenges and Success Strategies (2016)
Perioperative Nurse Leaders and Professionalism (2016)
B. SUMMARY
i. Introduction
In summary from what I’ve
read, the article first describes the
widely used OR checklist in the
Philippines: the WHO Surgical
Safety Checklist – as a sequence of
reminders that aim to develop
communication and prevent faults
or omissions in the operating room
(OR) patient care. It is administered
in three ‘domains’ summarized
here:
Sign in (when the patient
arrives in the OR);
Time Out (just prior to the
first surgical incision)
Sign Out (prior to the patient
leaving the OR).
Wherein standard OR practice under a paradigm in which the circulating nurse is responsible for
initiating and administering all three domains from a paper copy of the Checklist. However, to the analysis
of the research authors they found-
ii. Gap of the Study and Research Objective
Like other organizations who have reviewed their own experience, they have seen poor compliance
with administration of the Sign Out domain and varying administration of the various Checklist items listed
within each of the three domains. In addition, they have reported struggle in reliably achieving undistracted
engagement of OR team members in the administration process. Indeed, despite periodic reminders and
discussion about the importance of sound Checklist practice at staff forums, these Checklist practice metrics
showed no general trend to improvement (and in some respects deteriorated) between audits published in
2011 and 2013.
With this in mind, they’re objective was to: To evaluate engagement of operating room (OR) subteams
(anaesthesia, surgery and nursing), and compliance with administering checklist domains (Sign In, Time
Out and Sign Out) and checklist items, after introducing a wall-mounted paperless checklist with migration
of process leadership (Sign In, Time Out and Sign Out led by anaesthesia, surgery and nursing,
respectively).
iii. Methods
From an observation they had at a local hospital, they saw superior engagement in Checklist
administration wherein the Checklist was wall-mounted and each domain was led by a different OR
professional group (anaesthesia, nursing and surgery) hereafter referred to as ‘sub-teams’ of the overall OR
team. Specifically, anaesthesia led Sign In; surgery led time Out and nursing led Sign Out. With that
principle/paradigm in mind, the method was conducted via pre-post observational study in which 261
checklist domains in 111 operations were observed 2 months after changing the checklist administration
paradigm. Compliance with administration of the checklist domains and individual checklist items was
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recorded, as was the number of OR subteams engaged. Comparison was made with 2013 data from the
same OR suite prior to the paradigm change. Study conducted in Auckland New Zealand.
iv. Results & Findings
Analyzed from the results and discussions in the study, A comparison of our 2013 and 2015 data
demon-strates that implementation of the wall-mounted Checklist with migrated leadership in our operating
suite was associated with substantial improvements in the following: compliance with administration of the
Sign Out domain (22% of cases vs 84%, p<0.001); compliance with administration of the individual
Checklist items within all domains (Sign In 59.9% of eligible items vs 91.9%; Time Out 84.4% vs 92.9%;
Sign Out 80.0% vs 98.9%, p<0.001 in each case) and expected gold-standard subteam engagement within
all domains (Sign In 40% of cases vs 83%; Time Out 15% vs 84%; Sign Out 9% vs 22%, p<0.001 for each).
It is notable that during several hundred Checklist domain observations in our previous (2013) study, we
never recorded proper engagement of every staff member present in the OR during Checklist
administration.7 Although still far from universal in the present study, engagement of the entire OR team
was seen in at least some cases
C. REACTION & DISCUSSION:
1. Insights/Relevance to patients’ care/care
Summarizing points from the journal relevant to patient’s care:
• From the adoption of the wall mounted checklist format, anecdotally, the reading of the administering
person often seemed to draw the attention of other OR staff to the Checklist, thereby improving their
engagement in the process (rather like the use of visual aids in a lecture). The greater the engagement of
each member to the leader such as the nurse, empowers everyone to the precautions needed in the care of
the patient.
• Priority would be then duly given to the importance of providing quality care for each patient, reviewing
and going through each item, upholding safety, and preventing omissions and errors in care. This could
come in the form of sponge/instrument count and labelling. Especially when I or my clinical group are
immersed in duty with many patients, safety and standard of care comes first as a nurse and as a Louisan.
• As a student nurse doors have been open to an environment more exposed for opportunities to practice
quality improvements in the patient’s care considering the simple intervention of mounting the checklist
can impact care of patients so greatly.
2. Relevance to area of rotation/local setting/Phil.
Described in the article as well, in use of the paperbased Checklist (likened to the Philippines), they
commonly witnessed leader nurses reciting it from memory which often resulted in omission of items and
some-times the administration of confabulated ‘items’ not actually on the Checklist.
I personally experienced this while acting as a circulating nurse. Before the operation, I was
reviewing the paper while the staff nurse was reciting the checklist, in which they included items not in the
list.
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3. Relevance to Nursing Education, Practice and Research
That being said, nursing education and practice aim to find the most effective and efficient way to
deliver holistic care through evidenced based research and practice. Updates such these are massive leaps
towards nursing research, updating practices in nursing leadership in terms of the OR setting preventing
errors and omission, enhancing collaboration and promoting overall patient care.
In relation to nursing education, the WHO OR checklist, in my perspective, is a comprehensive
step-by-step set of guidelines and algorithms that can be easily practiced and integrated at the proper times,
being that it would be wall mounted. This ensured that in practice, together with the knowledge discussed
about the operating room, quality and standard are maintained.
4. Learning Insights on the Journal
Reiterating some points stated, significant gains in the compliance with the Surgical Safety
Checklist administration was acquired with the simple implementation of a wall mount and a leader-based
division of tasks throughout the team, strategically migrating leadership of the three Checklist domains
among the anaesthesia, surgical and nursing subteams. Leading to even greater gains to patient care.
Quality improvement that entails the collaboration of the different sectors of health care will always
be a step in the right direction and must be an ever grow branch taking in consideration eachothers role and
potential in leadership in that division.
References:
Ajorpaz, N. M., Tafreshi, M. Z., Mohtashami, J., Zayeri, F., & Rahemi, Z. (2018). The effect of mentoring on
clinical perioperative competence in operating room nursing students. Journal of Clinical Nursing, 25(9-10),
1319-1325. doi:10.1111/jocn.13205
Cox, J. A. (2016). Leadership and Management Roles: Challenges and Success Strategies. AORN Journal, 104(2),
154-160. doi:10.1016/j.aorn.2016.06.008
Ong, A. P., Devcich, D. A., Hannam, J., Lee, T., Merry, A. F., & Mitchell, S. J. (2018). A ‘paperless’ wall-mounted
surgical safety checklist with migrated leadership can improve compliance and team engagement. BMJ Quality
& Safety, 25(12), 971-976. doi:10.1136/bmjqs-2015-004545
Whiteside, D. (2016). Perioperative Nurse Leaders and Professionalism. AORN Journal, 104(2), 133-144.
doi:10.1016/j.aorn.2016.06.003World Health Organization. (2017) WHO Recommendations on Newborn
Health: Guidelines Approved by the WHO Guidelines Review Committee. Geneva: World Health
Organization.
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