Human factors approach to surgical safety checklist implementation

Yıl 2019, Cilt: 6 Sayı: 3, 211 - 217, 06.09.2019

Ozlem Soyer Meryem Yavuz Van Giersbergen

Öz

Introduction and Purpose: The goal of using a surgical safety checklist is to monitor critical safety processes in patient care and minimize the risks that can be avoided. In order to avoid preventable errors, it is important to systematically evaluate the effective facilitator and barrier factors in the implementation of the surgical safety checklist.. The aim of this study was to determine the facilitatorand barrier factors of applying the surgical safety checklist according to the SEIPS 2.0 model.

Material and Method: A qualitative research method was used in the study. The sample of the study consisted of 32 nurses working in surgical ward and operating room. The three focus group interview was used. A grounded theory approach was used to collect and analyze semi-structured interview data. Interview results were evaluated according to SEIPS 2.0 model.

Results and Conclusion: The facilitating themes were determined to be positive patient perception, legal liabilities and prevention of mistakes. The barrier themes were determined to be the resistance of the team members, the scarcity of nurses and time, the intensity of patients, the work load and team conflict.

All of nurses explained that surgical safety checklist was important on patient safety. All team members to fulfill their responsibilities in the implementation of the surgical safety  checklist is important.

Anahtar Kelimeler

Surgical Safety Checklist, Nursing, Focus Group

Güvenli cerrahi kontrol listesi uygulamasına insan faktörleri yaklaşımı

Öz

Giriş ve Amaç: Güvenli cerrahi kontrol listesi kullanımındaki amaç, hasta bakımında kritik güvenlik süreçlerini takip etmek ve önlenebilecek riskleri en aza indirmektir. Önlenebilir hatalardan kaçınmak için güvenli cerrahi kontrol listesinin uygulanmasında etkili kolaylaştırıcı ve engelleyici faktörlerin sistematik bir yaklaşımla değerlendirilmesi önemlidir. Bu çalışmanın amacı, hasta güvenliğinde kullanılan SEIPS 2.0 modeline göre güvenli cerrahi kontrol listesinin uygulanmasında kolaylaştırıcı ve bariyer faktörlerinin belirlenmesidir.

Gereç ve Yöntem: Bu araştırmada,  nitel araştırma yöntemi kullanıldı. Çalışmanın örneklemini cerrahi kliniklerde ve ameliyathanede çalışan 32 hemşire oluşturdu. Üç odak grup görüşmesi yapıldı. Yarı yapılandırılmış görüşme verilerini toplamak ve analiz etmek için temellendirilmiş kuram yaklaşımı kullanıldı. Görüşme sonuçları SEIPS 2.0 modeline göre değerlendirildi.

Bulgular ve Sonuç: Kolaylaştırıcı faktör temaları, olumlu hasta algısı, yasal yükümlülükler ve hataların önlenmesi olarak belirlendi. Engelleyen faktör temaları ise, ekip üyelerinin direnci, hemşire sayısının ve zamanın sınırlılığı, hastaların yoğunluğu, iş yükü ve ekip çatışması olarak belirlendi.

Tüm hemşireler güvenli cerrahi kontrol listesinin hasta güvenliği açısından önemli olduğunu belirtti. Tüm ekip üyelerinin güvenli cerrahi kontrol listesinin uygulanmasında sorumluluklarını yerine getirmeleri önemlidir.

Anahtar Kelimeler

Cerrahi Güvenlik Kontrol Listesi, Hemşirelik, Odak Grup

Kaynakça

• Weiser, T.G., Haynes, A.B., Molina, G., Lipsitz, S.R., Esquivel, M.M., Uribe-Leitz, T., Fu, R., Azad, T., Chao, T.E., Berry, W.R., Gawande, A.A. (2016). Size and distribution of the global volume of surgery in 2012. Bulletin of the World Health Organization, 94(3), 201-209.
• Anderson, O., Davis, R., Hanna, G.B., Vincent, C.A. (2013). Surgical adverse events: a systematic review. The American Journal of Surgery, 206(2), 253-262.
• World Health Organization-WHO. WHO Guidelines for Safe Surgery, Safe Surgery Saves Lives. Retrieved April 12, 2015. http://whqlibdoc.who.int/publications/2009/9789241598552_eng.pdf.
• The Ministry of Health of Turkey. Performance Management and Quality Improvement Department. Retrieved April 23, 2016. https://kalite.saglik.gov.tr/content/files/duyurular_2011/2011/09_ocak_2011/0901guvenlicerrahi.pdf. Carayon, P., Hundt, A.S., Karsh, B.T., Gurses, A.P., Alvarado, C.J., Smith, M., Flatley Brennan, P. (2006). Work system design for patient safety: The SEIPS model. Quality & Safety in Health Care, 15(suppl I), 50-58.
• Holden, R.J., Carayon, P., Gurses, A.P., Hoonakker, P., Hundt, A.S., Ozok, A.A., Rivera-Rodriguez, A.J. (2013). SEIPS 2.0: a human factors framework for studying and improving the work of healthcare professionals and patients. Ergonomics, 56(11), 1669-86.
• Wooldridge, A.R., Carayon, P., Hundt, A.S., Hoonakker, P.L.T. (2017). SEIPS-based process modeling in primary care. Applied Ergonomics, 60(2017), 240-254.
• de Vries, E.N., Prins, H.A., Crolla, R.M., den Outer, A.J., van Andel, G., van Helden, S.H., Schlack, W.S., van Putten, M.A., Gouma, D.J., Dijkgraaf, M.G., Smorenburg, S.M., Boermeester, M.A. (2010). Effect of a comprehensive surgical safety system on patient outcomes. The New England Journal of Medicine, 363(20), 1928-37.
• van Klei, W.A., Hoff, R.G., van Aarnhem, E.E., Simmermacher, R.K., Regli, L.P., Kappen, T.H., van Wolfswinkel, L., Kalkman, C.J., Buhre, W.F., Peelen, L.M. (2012). Effects of the introduction of the WHO "surgical safety checklist" on in-hospital mortality: A cohort study. The Annals of Surgery, 255(1), 44-49.
• Urbach, D.R., Govindarajan, A., Saskin, R., Wilton, A.S., Baxter, N.N. (2014). Introduction of surgical safety checklists in Ontario, Canada. The New England Journal of Medicine, 370(11), 1029-38.
• Haugen, A.S., Søfteland, E., Almeland, S.K., Sevdalis, N., Vonen, B., Eide, G.E., Nortvedt, M.W., Harthug, S. (2015). Effect of The World Health Organization checklist on patient outcomes: a stepped wedge cluster randomized controlled trial. Annals of Surgery, 261(5), 821-8.
• Sewell, M., Adebibe, M., Jayakumar, P., Jowett, C., Kong, K., Vemulapalli, K., Levack, B. (2011). Use of The WHO surgical safety checklist in trauma and orthopaedic patients. International Orthopaedics, 35(6), 897-901.
• Rosenberg, N.M., Urman, R.D., Gallagher, S., Stenglein, J., Liu, X., Shapiro, F.E. (2012). Effect of an office-based surgical safety system on patient outcomes, Eplasty, 12(e59), 493-99.
• Askarian, M., Kouchak, F., Palenik, C.J. (2011). Effect of surgical safety checklists on postoperative morbidity and mortality rates, Shiraz, Faghihy Hospital, a 1-year study. Quality Management in Health Care, 20(4), 293-7.
• Haynes, A.B., Weiser, T.G., Berry, W.R., Lipsitz, S.R., Breizat, A.H., Dellinger, E.P., Herbosa, T., Joseph, S., Kibatala, P.L., Lapitan, M.C., Merry, A.F., Moorthy, K., Reznick, R.K., Taylor, B., Gawande, A.A. (2009). A surgical safety checklist to reduce morbidity and mortality in a global population. The New England Journal of Medicine, 360(5), 491-9.
• Kwok, A.C., Funk, L.M., Baltaga, R., Lipsitz, S.R., Merry, A.F., Dziekan, G., Ciobanu, G., Berry, W.R., Gawande, A.A. (2013). Implementation of The World Health Organization surgical safety checklist, including introduction of pulse oximetry, in a resource-limited setting. Annals of Surgery, 257(4), 633-9.
• Weiser, T.G., Haynes, A.B., Dziekan, G., Berry, W.R., Lipsitz, S.R., Gawande, A.A. (2010). Effect of a 19-item surgical safety checklist during urgent operations in a global patient population. Annals of Surgery, 251(5), 976-80.
• Lübbeke, A., Hovaguimian, F., Wickboldt, N., Barea, C., Clergue, F., Hoffmeyer, P., Walder, B. (2013). Effectiveness of the surgical safety checklist in a high standard care environment. Medical Care, 51(5), 425-9.
• Lepänluoma, M., Rahi, M., Takala, R., Löyttyniemi, E., Ikonen, T.S. (2015). Analysis of neurosurgical reoperations: Use of a surgical checklist and reduction of infection-related and preventable complication-related reoperations. Journal of Neurosurgery, 123(1), 145-52.
• Takala, R.S., Pauniaho, S.L., Kotkansalo, A., Helmiö, P., Blomgren, K., Helminen, M., Kinnunen, M., Takala, A., Aaltonen, R., Katila, A.J., Peltomaa, K., Ikonen, T.S. (2011). A pilot study of the implementation of WHO surgical checklist in finland: improvements in activities and communication. Acta Anaesthesiologica Scandinavica, 55(10), 1206-14.
• Helmiö, P., Blomgren, K., Takala, A., Pauniaho, S.L., Takala, R.S., Ikonen, T.S. (2011). Towards Better Patient Safety: WHO Surgical Safety Checklist in Otorhinolaryngology. Clinical Otolaryngology, 36(3), 242-7.
• Rodrigo-Rincon, I., Martin-Vizcaino, M.P., Tirapu-Leon, B., Zabalza-Lopez, P., Zaballos-Barcala, N., Villalgordo-Ortin, P., Abad-Vicente, F.J., Gost-Garde, J. (2015). The effects of surgical checklists on morbidity and mortality: a pre- and post-intervention study. Acta Anaesthesiologica Scandinavica, 59(2), 205-14.
• Fargen, K.M., Velat, G.J., Lawson, M.F., Firment, C.S., Mocco, J., Hoh, B.L. (2013). Enhanced staff communication and reduced near-miss errors with a neurointerventional procedural checklist. Journal of Neurointerventional Surgery, 5(5), 497-500.
• Bashford, T., Reshamwalla, S., McAuley, J., Allen, N.H., McNatt, Z., Gebremedhen, Y.D. (2014). Implementation of the WHO Surgical Safety Checklist in an Ethiopian Referral Hospital. Patient Safety in Surgery, 8(16), 1-11.
• Hurtado, J.J., Jiménez, X., Peñalozo, M.A., Villatoro, C., de Izquierdo, S., Cifuentes, M. (2012). Accaptance of the WHO surgical safety checklist among surgical personnel in hospitals in Guatemala city. BMC Health Services Research, 12(169), 1-5.
• Haynes, A.B., Weiser, T.G., Berry, W.R., Lipsitz, S.R., Breizat, A.H., Dellinger, E.P., Dziekan, G., Herbosa, T., Kibatala, P.L., Lapitan, M.C., Merry, A.F., Reznick, R.K., Taylor, B., Vats, A., Gawande, A.A. (2011). Changes in safety attitude and relationship to decreased postoperative morbidity and mortality following implementation of a checklist-based surgical safety intervention. BMJ Quality and Safety, 20(1), 102-7.
• Omi, A., Terai, Y., Muro, D. (2014). Successful trial for introduction of the WHO surgical safety checklist. Masui, 63(1), 105-11.
• Norton, E.K., Rangel, S.J. (2010). Implementing a pediatric surgical safety checklist in the OR and beyond. AORN Journal, 92(1), 61-71.
• Paugam-Burtz, C., Guerrero, O. (2011). French surgical checklist in a universitary hospital: achievements one year after implementation. Annales Francaises D'anesthesie Et De Reanimation, 30(6), 475-8.
• Saturno, P.J., Soria-Aledo, V., Da Silva Gama, Z.A., Lorca-Parra, F., Grau-Polan, M. (2014). Understanding WHO surgical checklist implementation: Tricks and pitfalls. An observational study. World Journal of Surgery, 38(2), 287-95.
• Aveling, E.L., McCulloch, P., Dixon-Woods, M. (2013). A qualitative study comparing experiences of the surgical safety checklist in hospitals in high-income and low-income countries. BMJ Open, 3(8), e003039.
• Russ, S.J., Rout, S., Caris, J., Moorthy, K., Mayer, E., Darzi, A., Sevdalis, N., Vincent, C. (2014). The WHO surgical safety checklist: survey of patients’ views. BMJ Quality and Safety, 0, 1-8.
• Kariyoi, P.C., Hightoweri, J., Ndihokubwayoi, J.B., Tumusiimei, P., Mwikisa C. (2013). Challenges facing the introduction of the WHO surgical safety checklist: a short experience in African countries. African Health Monitor,16, 36-39.
• Fourcade, A., Blache, J., Grenier, C., Bourgain, J.L., Minvielle, E. (2012). Barriers to staff adoption of a surgical safety checklist. BMJ Quality and Safety, 21(3), 191-197.
• Bergs, J., Lambrechts, F., Simons, P., Vlayen, A., Marneffe, W., Hellings, J., Cleemput, I., Vandijck, D. (2015). Barriers and facilitators related to the implementation of surgical safety checklists: A systematic review of the qualitative evidence. BMJ Quality and Safety, 24, 776-778.