Implementation of the WHO Surgical Safety Checklist in an Ethiopian Referral Hospital

Abstract

BackgroundThe WHO Surgical Safety Checklist has a growing evidence base to support its role in improving perioperative safety, although its impact is likely to be directly related to the effectiveness of its implementation. There remains a paucity of documented experience from low-resource settings on Checklist implementation approaches. We report an implementation strategy in a public referral hospital in Addis Ababa, Ethiopia, based on consultation, local leadership, formal introduction, and supported supervision with subsequent audit and feedback.MethodsPlanning, implementation and assessment took place from December 2011 to December 2012. The planning phase, from December 2011 until April 2012, involved a multidisciplinary consultative approach using local leaders, volunteer clinicians, and staff from non-governmental organisations, to draw up a locally agreed and appropriate Checklist. Implementation in April 2012 involved formal teaching and discussion, simulation sessions and role play, with supportive supervision following implementation. Assessment was performed using completed Checklist analysis and staff satisfaction questionnaires at one month and further Checklist analysis combined with semi-structured interviews in December 2012.Results and discussionChecklist compliance rates were 83% for general anaesthetics at one month after implementation, with an overall compliance rate of 65% at eight months. There was a decrease in Checklist compliance over the period of the study to less than 20% by the end of the study period. The ‘Sign out’ section was reported as being the most difficult section of the Checklist to complete, and was missed completely in 21% of cases. The most commonly missed single item was the team introduction at the start of each case. However, we report high staff satisfaction with the Checklist and enthusiasm for its continued use.ConclusionWe report a detailed implementation strategy for introducing the WHO Surgical Safety Checklist to a low-resource setting. We show that this approach can lead to high completion rates and high staff satisfaction, albeit with a drop in completion rates over time. We argue that maximal benefit of the Surgical Safety Checklist is likely to be when it engenders a conversation around patient safety within a department, and when there is local ownership of this process.

The World Health Organization Surgical Safety Checklist Improves Post-Operative Outcomes: A Meta-Analysis and Systematic Review

“…Fourcade et al reported a checklist completion rate of only 61%, while other studies have reported completion rates as low as 21% [8]- [10]. Levy et al observed compliance rates among 142 pediatric surgical cases over a 7-week period, and reported that none of the cases completed the entire checklist, which was significantly lower than the hospital reported 100% compliance rate [6].…”

Implementation of the WHO Surgical Safety Checklist and surgical swab and instrument counts at a regional referral hospital in Uganda – a quality improvement project

“…There are unique challenges to implementation of the WHO checklist in resource‐limited settings. These include local healthcare infrastructure, access to basic resources, safety culture and sociocultural norms among healthcare workers .…”

An investigation of barriers to the use of the World Health Organization Surgical Safety Checklist in theatres

“…[13] In Pakistan, initial checklist compliance was 20.4%, which increased to 89.9% after 4 years. [14] Bashford et al [15] showed a decline in the compliance rate -from 83% one month after implementation to 18% eight months after implementation.…”

“…A Pakistani study [14] showed a greater than 4-fold increase in compliance over a 4-year period as training continued and momentum to SSCL use developed. Contradictorily, an Ethiopian study [15] showed a decrease from 83% to 18% in SSCL use over 8 months after implementation, despite ongoing training. In our cohort, 12% of all respondents indicated that inadequate training was a barrier, but 85.9% perceived the need for staff to be trained.…”