IS THERE ANY EVIDENCE THAT USING ADAPTED WORLD HEALTH

ORGANISATION SURGICAL SAFETY CHECKLIST CAN CAUSE MORE

INCIDENTS, ERRORS AND ‘NEVER EVENTS’?

Introduction

The purpose of this study is to explore the use of adapted World Health Organisation
surgical Safety checklist (WHO SSC) in operating theatres. The study seeks to
answer the research question, is there any evidence that using adapted WHO SSC
can cause more incidents, errors and never events? The National Patient Safety
Agency (NPSA), in conjunction with a multi-professional expert reference group, has
adapted the checklist for use in England and Wales. This checklist contains the core
content but can be adapted for specific specialties through usual clinical governance
procedures (National Patient Safety Agency, 2009). This project will introduce the
reader to the Adapted WHO SSC and the author will explore to find out if there is any
evidence that When Operating Department Practitioners (ODPs) are using the
adapted WHO Surgical checklist, they are more likely to cause more errors. Before a
patient is taken into theatre, it is the role of the ODP to carry out all the relevant
surgical safety checks as per the World Health Organization (WHO) launched in
June 2009. This project will review literature that is relevant to the topic above,
evaluate the literature and identify the key themes. The aims and objectives will be
listed, the research types will be explored and finally, a description of where the
literature was obtained will be included.

Key evidence to support the discussion will be driven from National Institute for
Health and Care Excellence (NICE) evidence search, journal articles in nursing and
allied health (CINAHL), journal articles in medicine and health (PUBMED), journal
articles and other materials (SCOPUS), local hospital policies and procedure and
evidence-based practice.
Initial Literature Review

There have been many studies carried out that related to Adaptation of the WHO
SSC which has paid attention to the implementation of surgical checklist, barriers
and facilitators related to the implementation of WHO SSC. These are the three main
key themes which have been identified. This project will concentrate on finding out if
practitioners are more likely to cause errors by using these adapted checklists.

Levy et al. (2012) carried out a quantitative research study on implementing a

surgical checklist on paediatric surgical operations in the United States of America
(USA). This was direct observation of 142 cases and a survey was used as well. The
research identified barriers related to the implementation of surgical safety checklist
to include lack of understanding of checklist points, jobs role was not clear among
team members, lack of education, poor implementation process, lack of honesty in
the checklist. The same study recommended that the checklist should not be
memorised instead it should be read, proper education should be on the new patient
safety practices. This research leads to conclude that an adapted checklist might be
more fitting in the specialty of pediatrics, but more research needs to be done.

Another mixer of both qualitative and quantitative study was carried out by Vere and
Gopalam (2018) to investigate barriers to the use of the WHO surgical safety
checklist in theatres in Durban, South Africa over a 2-week period. The barriers were
the same as those mentioned by Raman et al. (2016) and Fourcade et al. (2011).
The results showed a reduction in complications in centres where the checklist was
implemented. This relates well with the topic to show the advantages of an adapted
checklist. But moreover, more research is required to investigate the problems
related to using the adapted checklist as well.

Another qualitative research study was carried out by Fourcade et al. (2011),
investigating the barriers to staff adoption of a surgical safety checklist within five
centres in France. 11 barriers to effective checklist were identified which were like
those stated by Raman et al. (2016). The results showed that practitioners had
problems with using the adapted checklist following the implementation and in the
centers that had poor results, the staff members had not been involved in the
implementation of the checklist.

Bohmer et al. (2011) completed a qualitative study to find out if the implementation of
a perioperative checklist increases patient perioperative safety and staff satisfaction
in German. It was identified that the success in this study was because the staff were
involved in the implementation and that the checklist was adapted specifically to the
setting contrary to the findings of Fourcade et al. (2011) where staff were not
involved in the implementation process.
Molina et al. (2017) undertook both qualitative and qualitative research study on the
implementation of an adapted safe childbirth checklist in rural Chiapas, Mexico. The
results practitioners were using the new checklist which should appositive impact on
the usage. However, the qualitative interviews showed some variation in terms of
birth experiences.

Another qualitative research study was carried out by Raman et al. (2016) to look at
ways to improve a checklist when the contents are not enough and to understand
why time outs and checklists are sometimes not effective in preventing surgical
adverse events and to look at how these events can be reduced. The results showed
thirty events occurred and this was as a result of poor communication between staff,
medication errors, missing instruments, missing implants, and equipment issues.
The study concluded that time outs and checklists can prevent some types of
adverse events if they are properly designed and the modification of checklists for
specialized surgical procedures may reduce adverse events. However, more
research is required to identify if there are other types of events that can occur, and
this relates well to the topic of research

Lastly, Bergs et al. (2015) carried out a qualitative study to obtain an understanding
of barriers related to the implementation of WHO SSC in Belgium. The results found
that the implementation of a surgical safety checklist required staff to change their
perception regarding the checklist and the changes on the checklist should be
relevant to the specific setting.

These research studies have been chosen because they are relevant to the topic
and easy to understand though the data collected by Bohmer et al. (2011) was
complicated and not easy to understand. The articles were valid even though some
of the articles were published back in 2012 while others 2018 and they support the
topic. These articles are international as they have been published from different
parts of the world to include Dubai, South Africa (Verwey and Gopalan, (2018),
Mexico Levy et al., 2012), USA (Raman et al., 2016), France (Fourcade et al., 2011).
Therefore, the results have compared issues worldwide and the barriers identified
are similar in these countries. This shows that the problems encountered in these
adapted checklists, are worldwide and not just a problem in one country. It is a global
issue that needs addressing and that is why these barriers are being picked up by
different authors and this relates well with the topic.

These studies have greatly depended on other articles from other researchers and
therefore their evidence is not based on first-hand research or study. However, the
contents are well explained, they included statistics which were easy to interpret.
They have used various methods of approach to gather their data such as qualitative
and quantitative.
Justification

The author chose this topic to find out if there is evidence to show, that using
adapted WHO SSC causes more errors, incidents and never events.

Despite widespread adoption WHO SSC, “never events and other related serious
incidents still occur in theatres (Schwendimann et al., 2019). That is the main reason
for this project to explore to find out why these incidents are still occurring in
operating theatres, despite the use of adapted WHO SSC.

Several studies have addressed the benefits of using adapted WHO SSC for
example (Raman et al., 2016) confirms from their findings that adapted checklist for
specialised surgical procedure may reduce adverse events, there is a mention of
only three types of event and there are more events listed on the “never Event list
that was produced in 2018 ( Never Events, 2018). Therefore, this topic is of interest
to finding out if using adapted checklist increases the chances of making more errors
and if so, what types of errors are they and how can they be prevented in the future.

This topic is unique and important because by identifying errors, incidents and never
event associated with the use of the adapted WHO checklist, the user can then
decide whether they want to make changes to the safety checklist to make it more fit
for their purpose. There is no need to continue using a checklist that is causing more
problem than the intended good. The purpose of Adapted WHO SSC is to help the
ODP to follow a set of few critical safety lists which when followed could reduce the
most common and avoidable risks that endangers the lives and wellbeing of the
surgical patient (NHS, 2016). The healthcare professionals have a duty of how care
is delivered to their patients and therefore staff must ensure they do not cause any
harm to patients by negligence (The Association for Perioperative Practice, 2012).

Another supportive reason for choosing this topic is based on evidence from practice
during author’s placement. It has been observed when staff move from one
specialty to another, staff find they are not familiar with the contents list and this
increases the chances of causing more errors. Therefore, more research on this
topic is required as it is an important part of patient safety in the operating theatre. It
is a new topic but forms an important part of patient safety and it would be useful for
the world to read because WHO SSC is worldwide checklist

Aims and Objectives

This research will focus to find out the following;

1. The main purpose of the existing WHO SSC and why it was launched in 2009?

2. Why some specialities are adapting their own WHO SSC

3. What are the problems encountered while using this adapted WHO SSC?

4. To identify reasons and barriers for poor compliance and implementation of these
checklists.

5. To find out and identify perioperative safety standards which could otherwise
improve the implementation process and therefore reduce the errors.

Research types

There are two types of research methods that can be used to correct information
namely; primary and secondary. Primary research is the process of gathering fresh
data and this can be carried out through telephone interviews, postal survey, direct
observations, or faces to face interviews (Wikipedia contributors, 2019).
This type of research contains actual figures and actual evidence which should be
correct, valid, because researchers can be held accountable to the public for giving
false information (Wikipedia contributors, 2019). On the other hand, secondary
research involves the use of second-hand information from journal articles, websites
that had already been collected previously and published through primary research
(Wikipedia contributors, 2019).

For this piece of literature, secondary research method has been used to gather all
the necessary information. Relating ethics to this research, it can be confirmed that
the secondary materials used are valid, educative and the author finds them useful in
supporting their literature research. At the begging of every article, researchers have
made it clear, what their aims and objectives and the author feels that their aims and
objectives were met. Confidentiality was also maintained throughout these articles as
no names of the patient or practitioners were exposed. The materials that have been
used to produce for this project are therefore valid and the studies are from
trustworthy websites.

Accessing literature

To obtain the relevant literature, the author has used PubMed which has references
from biomedical journals and has been put together by the US National Library of
medicine and it includes references from Medline as well.

Another database that has been used is CINAHL plus with full text which has
journals in nursing, midwifery, physiotherapy, operating department practice and
other areas relating to allied health.

The actual search was performed in Medline, PubMed using the following query: an
adapted checklist. Broader search terms were applied such as barriers to adapted
WHO SSC but there were no good outcomes of related articles.
The search was narrowed down to “WHO surgical checklist”. and this way related
articles were found. Citethisforme websites was used to get the other related articles.
The tittle “WHO SSC” typed under bibliography, journal and using Harvard style and
a whole list of related studies were found and the most relevant were used.
Conclusion

The WHO SSC was developed in 2009 with the aim to decrease errors and adverse
events in surgery (WHO, 2009). WHO SSC is globally used to ensure patient safety
is maintained in operating rooms.

As the research has demonstrated if an adapted checklist is correctly implemented,

they could reduce complications and therefore improve patient outcome (Verwey and
Gopalan, 2018). The same authors have found that a good implementation strategy
should be planned before the adaptations takes place and staff members should be
involved.

This study has outlined the most common practices that can be used to make sure
that the adapted WHO surgical checklist is used effectively to improve patient
outcome. Despite widespread adoption of WHO SSC, “never events and other
related serious incidents are still occurring which could be due to problems regarding
compliance to the checklist (Schwendimann et al., 2019). Why are there still
incidents, errors and never events occurring in operating rooms? Clearly, there is
need to find out how these adverse events can be prevented in the first place.
Therefore, this project will seek to interview practitioners to find out their perception
towards using the adapted checklist in different specialties and the project proposes
to carry out a direct observation on practitioners while they use the adapted
checklist. This will aim to find out how errors are made and what these errors are.
These two mixed qualitative and quantative methods of research will hopefully
identify the root cause of these errors and never events. This will also aim to identify
how best these adapted checklists can be implemented and used. All healthcare
professionals have a duty to treat the patient with care and dignity and this includes
ensuring that they do not come to harm while in the healthcare establishment.