In a comparison of 3760 patients observed before implementation of the checklist with 3820 patients observed after implementation, the total number of complications per 100 patients decreased from 27.3 (95% confidence interval [CI], 25.9 to 28.7) to 16.7 (95% CI, 15.6 to 17.9), for an absolute risk reduction of 10.6 (95% CI, 8.7 to 12.4). The proportion of patients with one or more complications decreased from 15.4% to 10.6% (P<0.001). In-hospital mortality decreased from 1.5% (95% CI, 1.2 to 2.0) to 0.8% (95% CI, 0.6 to 1.1), for an absolute risk reduction of 0.7 percentage points (95% CI, 0.2 to 1.2). Outcomes did not change in the control hospitals. Conclusions Implementation of this comprehensive checklist was associated with a reduction in surgical complications and mortality in hospitals with a high standard of care. (Netherlands Trial Register number, NTR1943.)

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Effect of a comprehensive surgical safety system on patient outcomes

Background Formal evaluations of programmes are an important source of learning about the challenges faced in improving quality in healthcare and how they can be addressed. The authors aimed to integrate lessons from evaluations of the Health Foundation's improvement programmes with relevant literature.

Methods The authors analysed evaluation reports relating to five Health Foundation improvement programmes using a form of ‘best fit’ synthesis, where a pre-existing framework was used for initial coding and then updated in response to the emerging analysis. A rapid narrative review of relevant literature was also undertaken.

Results The authors identified ten key challenges: convincing people that there is a problem that is relevant to them; convincing them that the solution chosen is the right one; getting data collection and monitoring systems right; excess ambitions and ‘projectness’; organisational cultures, capacities and contexts; tribalism and lack of staff engagement; leadership; incentivising participation and ‘hard edges’; securing sustainability; and risk of unintended consequences. The authors identified a range of tactics that may be used to respond to these challenges.

Discussion Securing improvement may be hard and slow and faces many challenges. Formal evaluations assist in recognising the nature of these challenges and help in addressing them.

https://qualitysafety.bmj.com/content/qhc/21/10/876.full.pdf

Ten challenges in improving quality in healthcare: lessons from the Health Foundation's programme evaluations and relevant literature.

Background Surgical complications represent a significant cause of morbidity and mortality with the rate of major complications after inpatient surgery estimated at 3–17% in industrialised countries. The purpose of this review was to summarise experience with surgical checklist use and efficacy for improving patient safety.

Methods A search of four databases (MEDLINE, CINAHL, EMBASE and the Cochrane Database of Controlled Trials) was conducted from 1 January 2000 to 26 October 2012. Articles describing actual use of the WHO checklist, the Surgical Patient Safety System (SURPASS) checklist, a wrong-site surgery checklist or an anaesthesia equipment checklist were eligible for inclusion (this manuscript summarises all but the anaesthesia equipment checklists, which are described in the Agency for Healthcare Research and Quality publication).

Results We included a total of 33 studies. We report a variety of outcomes including avoidance of adverse events, facilitators and barriers to implementation. Checklists have been adopted in a wide variety of settings and represent a promising strategy for improving the culture of patient safety and perioperative care in a wide variety of settings. Surgical checklists were associated with increased detection of potential safety hazards, decreased surgical complications and improved communication among operating staff. Strategies for successful checklist implementation included enlisting institutional leaders as local champions, incorporating staff feedback for checklist adaptation and avoiding redundancies with existing systems for collecting information.

Conclusions Surgical checklists represent a relatively simple and promising strategy for addressing surgical patient safety worldwide. Further studies are needed to evaluate to what degree checklists improve clinical outcomes and whether improvements may be more pronounced in particular settings.

https://qualitysafety.bmj.com/content/qhc/23/4/299.full.pdf

Surgical checklists: a systematic review of impacts and implementation

Background
Underlying systems factors have been seen to be crucial contributors to the occurrence of medication errors. By understanding the causes of these errors, the most appropriate interventions can be designed and implemented to minimise their occurrence.

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Causes of Medication Administration Errors in Hospitals: a Systematic Review of Quantitative and Qualitative Evidence

Objective:To evaluate the effect of implementation of the WHO's Surgical Safety Checklist on mortality and to determine to what extent the potential effect was related to checklist compliance.Background:Marked reductions in postoperative complications after implementation of a surgical checklist hav

Effects of the introduction of the WHO "Surgical Safety Checklist" on in-hospital mortality: a cohort study.

Introduction: Adverse events in hospitals constitute a serious problem with grave consequences. Many studies have been conducted to gain an insight into this problem, but a general overview of the data is lacking. We performed a systematic review of the literature on inhospital adverse events. Methods: A formal search of Embase, Cochrane and Medline was performed. Studies were reviewed independently for methodology, inclusion and exclusion criteria and endpoints. Primary endpoints were incidence of in-hospital adverse events and percentage of preventability. Secondary endpoints were adverse event outcome and subdivision by provider of care, location and type of event. Results: Eight studies including a total of 74 485 patient records were selected. The median overall incidence of inhospital adverse events was 9.2%, with a median percentage of preventability of 43.5%. More than half (56.3%) of patients experienced no or minor disability, whereas 7.4% of events were lethal. Operation- (39.6%) and medication-related (15.1%) events constituted the majority. We present a summary of evidence-based interventions aimed at these categories of events. Conclusions: Adverse events during hospital admission affect nearly one out of 10 patients. A substantial part of these events are preventable. Since a large proportion of the in-hospital events are operation- or drug-related, interventions aimed at preventing these events have the potential to make a substantial difference.

https://qualitysafety.bmj.com/content/qhc/17/3/216.full.pdf

The incidence and nature of in-hospital adverse events: a systematic review

Introduction: A large number of preventable adverse events are encountered during hospital admission and in particular around surgical procedures. Checklists may well be effective in surgery to prevent errors and adverse events. We developed, validated and evaluated a SURgical PAtient Safety System (SURPASS) checklist. Methods: A prototype checklist was constructed based on literature on surgical errors and adverse events, and on human-factors literature. The items on the theory-based checklist were validated by comparison with process deviations (safety risk events) during real-time observation of the surgical pathway. Subsequently, the usability of the checklist was evaluated in daily clinical practice. Results: The multidisciplinary SURPASS checklist accompanies the patient during each step of the surgical pathway and is completed by different members of the team. During 171 high-risk surgical procedures, 593 process deviations were observed. Of the deviations suitable for coverage by a checklist, 96% corresponded to an item on the checklist. Users were generally positive about the checklist, but a number of logistic improvements were suggested. Conclusion: The SURPASS checklist covers the vast majority of process deviations suitable for checklist assessment and can be applied in clinical practice relatively simply. SURPASS is the first validated patient safety checklist for the entire surgical pathway.

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E N de Vries

Papers

The incidence and nature of in-hospital adverse events: a systematic review

Development and validation of the SURgical PAtient Safety System (SURPASS) checklist

WHO's checklist for surgery: don't confine it to the operating room