Cuenca, Ecuador: Study says poor adherence to WHO surgical safety checklist

annalsofglobalhealth.org/ S. Beache
, J.C. Puyana / Perceptions and adherence to the World Health Organization surgical safety checklist in Cuenca, Ecuador 1 Year post-educational intervention

Background

Surgical safety is an emerging global health priority. The World Health Organization’s Surgical Safety Checklist has been shown to be effective in reducing adverse surgical outcomes in this context. A 2014 study of Canadian hospitals failed to replicate these findings; authors’ commentary attributed the results to poor Checklist adherence amongst hospital staff. In 2014, our group investigated Checklist implementation at 2 hospitals in Cuenca, Ecuador that had recently integrated the Checklist into surgical workflow. Surgical observations and questionnaires to hospital staff revealed suboptimal adherence. Investigators developed a multi-tiered intervention program that included pamphlets, lecturers, and posters of the Checklist for the OR; the impact of these interventions on adherence has not been described. We hypothesized: 1) Interventions will improve Checklist adherence; and 2) Adherence is associated with positive perceptions about the Checklist and use of the Educational Interventions.

Methods

Between 06/2014 and 08/2014, a serial cross sectional study design was implemented at two hospitals. Surgical observations measured verbal confirmation of the WHO Checklist’s 19 steps by the appropriate surgical staff in their prescribed order (“pre-anesthesia”, “pre-incision”, “pre-exit from the OR”). Questionnaires were administered to surgeons, anesthesiologists, and nurses. Questionnaires assessed perceptions of the Checklist, interventions, and surgical safety. Responses were compared among surgical staff position and hospital site using ANOVA, T-test, and Chi-squared analyses.

Findings

45 surgeries were observed. Adherence to “pre-incision” Checklist items decreased significantly from 2014 to 2015 (P = 0.026). The questionnaire response rate was 93%, with a total of 91 questionnaires administered. On a 1-10 scale, the mean rating of Checklist effectiveness was high, at 9.01 (SD = 1.54). There was no association between adherence and Checklist perceptions or educational intervention use. Perceived unavailability of hard copies of the Checklist, lack of time and motivation to complete the Checklist were frequently identified barriers to adherence.

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Interpretations

While educational interventions are still widely used amongst surgical staff, introducing these interventions did not result in better adherence. In this population, future training programs that prioritize making the Checklist widely accessible may improve adherence and surgical team communication. Read Article