Create an analysis of the factors that contribute to the non-adherence of the perioperative surgical team discussed in this article.
Please read the following article:
Manamela, L. M., Rasweswe, M. M., & Mooa, R. S. (2022). Factors contributing to non-adherence of the peri-operative surgical team to WHO surgical safety checklist in the Kingdom of Saudi Arabia. Perioperative Care and Operating Room Management, 29. https://doi.org/10.1016/j.pcorm.2022.100292
Create an analysis of the factors that contribute to the non-adherence of the perioperative surgical team discussed in this article. Present a plan to overcome these barriers so that the surgical risks are reduced and quality and patient safety are improved.
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Factors contributing to non-adherence of the peri-operative surgical team to WHO surgical safety checklist in the Kingdom of Saudi Arabia Lorraine Motlalepula Manamelaa,*, Melitah Molatelo Raswesweb, Ramadimetja Shirley Mooaa aDepartment of Nursing Sciences, Faculty of Health Sciences, University of Pretoria, Gauteng Province, South Africa bDepartment of Nursing Science, Faculty of Health Sciences, University of Limpopo, Limpopo Province, South Africa ARTICLE INFO Keywords: Adherence Factors Kingdom of Saudi Arabia Non-adherence Peri-operative surgical team Surgical Safety Checklist Who Health Organization ABSTRACT Introduction: The World Health Organization Surgical Safety Checklist addresses acceptable practices for patient safety. This paper aimed to explore and describe the factors that contribute to non-adherence of peri‑operative surgical team to WHO surgical safety checklist at the selected hospital in the Kingdom of Saudi Arabia. Methods: The study adopted a qualitative design. The population consisted of a 12 peri‑operative surgical team with an average of 12 years’ experience in their respective medical fields. This population was purposely selected from a selected hospital operating theatres in Saudi Arabia. Non-probability purposive sampling was used to select the participants. Data was collected by means of semi-structured individual interviews. Content analysis was used to analyze data. Results: The findings revealed that peri‑operative surgical team experience challenges when implementing WHO SSC (2008). The challenges affect their adherence, which depends on a convergence of intertwined factors, such as the use of WHO SSC related to issues in the checklist steps and uncertainties regarding the safe use of WHO SSC, team factors, checklist items factors and procedural factors. Conclusion: The study clearly identified factors that contributed to suboptimal WHO SSC execution by peri‑op-erative surgical team in the Kingdom of Saudi Arabia, addressed at the institutional level. It is therefore important for the managerial teams to be supportive to the surgical perioperative team to improve adherence to WHO SSC. Support can be provided through continuous supervision, in-service training, mentoring, evaluation and awarding merits for the good adherence to patient safety. Furthermore, these findings can be used to develop strategies to promote perioperative surgical team adherence to WHO SSC and can be used for further research. 1.Introduction and background The Surgical Safety Checklist (SSC) is the guide that was developed in 2008 after World Alliance for Patient Safety launched the Safe Sur-gery Saves Lives campaign through World Health Organization (WHO). The main aim was to standardize peri-operative care and reduce the number of surgical mishaps across the world by either preventing an error from occurring or from causing any harm to the patient 1. The guide also focuses on improving the communication and safety attitudes among operating theater staff [ibid]. The WHO SSC consists of many items or elements and processes to be followed by the peri‑operative surgical team prior, during and after the surgical procedure and it is divided into three phases: sign in before induction of anesthesia, time out/surgical pause before skin incision, and sign out before patient leaves operating room 1. The items included in three phases assist in ensuring that peri‑operative surgical team consistently follow critical safety steps, thus minimizing avoidable risks of endangering the lives of patients who undergo surgery 2. The implementation of this checklist in operating rooms in a range of settings showed marked reduction in surgical mishaps and improvement in communication among the team members. For example, a relative reduction of the postoperative complication of 36% was observed in one study 1. In Scotland, a reduction of 36⋅6 (95 percent c.i. –55⋅2 to –17⋅9) percent in mortality (P <0⋅001) was reported 3. While, in a cohort study crude mortality decreased from 3.13% – 2.85% (P =0.19) 4. A lowered mortality rate (odds ratio, 0.49; 95% CI, 0.32 to 0.77) was also reported after the use of WHO SSC 5. Improved surgery outcomes were also observed in high-risk pediatric surgery in developing countries 6. The recent study conducted in China revealed that to date the WHO SSC is still an effective instru-ment capable to improve surgical patient safety 7. Moreover, WHO *Corresponding author at: Institution: University of Pretoria, LinkedIn- Lorraine Motlalepula Manamela, Postal address: University of Pretoria. E-mail address: [email protected] (L.M. Manamela). Contents lists available at ScienceDirect Perioperative Care and Operating Room Management journal homepage: www.elsevier.com/locate/pcorm https://doi.org/10.1016/j.pcorm.2022.100292 Received 17 January 2022; Received in revised form 12 August 2022; Accepted 12 October 2022
recommends that all the operating room facilities should follow the SSC guide globally. However, despite the suggested effectiveness of safety check lists, the practices in different settings are debatable due to the reported non-adherence rate 8. The selected hospital adopted and implemented the WHO SSC before the year 2015 using a manual recording. In the year 2017 the hospital upgraded to the electronic format. Despite a successful implementation of the electronic format, which produced high documented adherence rate, on the actual observation and during the audit, the adherence was low(below 100% which is the set target). When the first author audited 16 files in November 2017 on the electronic system, all items were ticked off yet on observation some items were not called out. Therefore, recorded adherence was found unreliable and significantly higher than observed adherence. All of this indicated that there were certain process defects that needed to be identified and improved. A systematic review and meta-analysis of the effect of the World Health Organization sur-gical safety checklist on postoperative complications revealed the same 9. The study conducted in Queensland university hospital, Australia also reported both high and low adherence 10. Abbott et al. 5 revealed that in many countries, the adherence rate of surgical safety checklist has badly decreased due to the multiple factors that hindered its implementation. In the operating theatres of United States of America non-adherence caused 40% of adverse errors that would have been prevented if WHO SSC steps were followed 11. In the Kingdom of Saudi Arabia, there are few research studies that have been done to investigate factors that contribute to non-adherence of the peri‑operative surgical team to WHO surgical safety checklist. Adherence to WHO SSC should be considered critical to patient safety and may not be achieved if factors contributing to non-adherence are not investigated among a peri‑operative surgical team. Non-adherence to the WHO SSC might place patients at risk of “never events” like retained foreign objects, for example: sponges and instruments; wrong patient surgery, wrong site surgery, wrong procedure, and more [11,12]. Un-derstanding these factors may be necessary to identify and address adherence issues and ensure that WHO SSC use is sustained. Hence this study was conducted to fill the identified gaps. The focus was on the factors that contribute to non-adherence of peri‑operative surgical team to WHO surgical safety checklist at the selected hospital in the Kingdom of Saudi Arabia. 2.Method 2.1.Design A qualitative design was employed to answer the research question, which was what are the factors that contribute to non-adherence of peri‑operative surgical team to WHO SSC at the selected hospital in the Kingdom of Saudi Arabia. Probing questions followed based on the answer provided by each participant. A purposive qualitative approach was employed to select the participants. 2.2.Setting and participants The study was conducted in a private secondary hospital with nine (9) operating theatres in Kingdom of Saudi Arabia. The hospital is accredited by the Joint Commission International (JCI) and by the Saudi Central Board for Accreditation of Healthcare Institutions (CBAHI). The participants of this study were a multicultural, multinational peri‑op-erative surgical team coming from different countries but working in the selected operating theater during data collection. The sample was cho-sen purposively as it consisted of a perioperative surgical team that were in contact with patients who undergo surgery daily and knowledgeable about WHO SSC because they utilize it regularly. The study included registered peri‑operative nurses, qualified surgeons and anesthesiolo-gists. Post-anesthesia care registered nurses, operating theater technol-ogists and assistant surgeons were excluded. 2.3.Data collection Data were collected between October 2020 and March 2021 using face-to-face semi-structured interviews. Face to face interviews allowed an opportunity to flexibly observe and explore nonverbal expressions such as body movements displayed by the participants when responding to questions. This assisted the researchers to be aware of any distortions or inaccuracies in the information provided by the participants. Meeting participants in person did not overstep the Covid-19 restrictions because at the time of data collection, the Kingdom of Saudi Arabia had less reported Covid-19 cases and safety precautions were followed as advised by infection control protocol. The conference room of the operating theater which accommodate 12 people was utilized as the venue for interviews for registered nurses and anesthetists, whereas surgeons’ interviews were conducted in their consultation rooms outside the operating theater complex. Permission to collect data and cooperation from the operating the-ater manager had been ensured in advance. The English language was used during interviews because the participants were multiracial and able to understand and speak in English as a medium of the instruction in the selected hospital. Each interview was limited between 45 and 60 min for the researcher to gather sufficient information while avoiding participant exhaustion. All the interviews were audio recorded as per participant verbal consent. Data collection continued until reaching a criterion for discontinuing data collection (data saturation), which took place when the participants provided no new information to the ques-tions asked. The data saturation was reached with participant number 10. However, 2 more participants were interviewed to ensure that the study does not omit any other different information that may emerge after concluding that saturation is reached. 2.4.Data analysis In this study, data analysis was performed concurrently with data collection using content data analysis with an inductive approach. Participants’ narratives formed the units of analysis and meaning units, in which words or whole phrases were identified and consolidated into themes or categories. The process included coding, categorizing, and classifying the emerging meaning units into similar sub-categories. These sub-categories were then interpreted according to their content and meaning, before been grouped into broader themes. The Atlas.ti, qualitative data analysis software, its headquarters based in Berlin, Germany, was used to confirm the emerged categories and codes, and unique codes were assigned to the dialog concepts. Similar topics were clustered together and formed into drawn columns. Then similar topics were arranged into major topics, unique topics, and irrelevant issues. Manually the researchers reduced the total list of categories by grouping the topics related to each other. Lines were drawn between the cate-gories, separating them according to their relationship and continually comparing manual analysis with the results generated by Atlas.ti soft-ware. The codes were then combined into super codes, which were then compared with the manually coded data and used to formulate relevant themes. The emerging themes were then integrated with the initial meanings of the units and formed the basis for the presentation of the findings, including a selection of illustrative quotations. 2.5.Trustworthiness The following measures of trustworthiness were applied: credibility, dependability, confirmability, and transferability. Credibility was ensured by means of prolonged engagement with the participants and clarifying some issues with the participants through probing. Depend-ability was attained by describing the study process and methods used in data collection. The independent co-coder, who was familiar and experienced with the process of qualitative data analyses was used, to verify emerged themes. To achieve confirmability audio recording were L.M. Manamela et al.
used and listened several times during data analysis. The raw data (recorded interviews and transcripts) are kept for safe and will be dis-carded after five years as advised by the University standards. The in-dependent coder was also consulted to confirm the transcripts and analyzed data. To achieve transferability, the researcher ensured that a comprehensive description of the research process and data analysis are provided in detail for other researchers to apply or use in similar set-tings. The researchers also ensured realization of the sample by purpo-sively selecting peri‑operative team members who are familiar with WHO SSC. 2.6.Ethical considerations Ethics approval was obtained from the University (Ref No. 530/ 2020) and permission to conduct the study was sought from the program Director Office/CEO in a selected hospital and the Director of Nursing. In addition, prior to the interviews, all participants signed an informed written consent document and were given an information sheet that explained the research’s goals. Furthermore, participants were informed that they were under no obligation to participate, and that their privacy would be protected as their names won’t be mentioned anywhere in the study. We also advised participants of their rights to discontinue participation anytime during the data collection period. 3.Findings and discussions 3.1.Participants demographic profile The demographic profile comprised twelve (12) participants, in which two (2) were male anesthesiologists, eight (8) registered nurses were females, and two (2) were male surgical specialists. Their ages varied from thirty (30) to fifty (50) years old. Their years’ experience in the health care area varied from ten (10) to nineteen (19) years. During data collection, all the participants were working at the selected hos-pital. Their ethnic group comprised four (4) Saudis, one (1) Pakistani, two (2) Asian/Filipino, and five (5) Asian/Indians among the participants. 3.2.Factors contributing to non-adherence of the peri‑operative surgical team to WHO SSC Four themes emerged describing factors contributing to non- adherence of the peri‑operative surgical team to WHO SSC: the use of WHO SSC factors, team factors, checklist factors and procedural factors. The themes, categories and subcategories that emerged from the data analysis are summarized in Table 1. 3.2.1.Theme 1: Use of WHO SSC factors The routine use of WHO SSC is recommended to reduce perioperative errors and its complications. The WHO SSC has numerous steps in a form of a checklist to be completed by surgical team collectively. It is there-fore, important to educate the surgical team on why the use of WHO SSC is important during implementation and through in-service sessions. The participants in our study considered the use of WHO SSC as a factor that contributes to the non-adherence by the peri‑operative surgical team. This was related to issues in the checklist steps and uncertainties regarding the safe use of WHO SSC. 3.2.1.1.Checklist steps and uncertainty regarding the safe use of WHO SSC.Difficulties in following the steps on the checklist and uncertainty regarding the safe use of WHO SSC were verbalized and often related to lack of knowledge regarding the importance of following WHO SSC, lack of awareness of checklist elements/ vital checklist items omitted and using the surgical safety checklist as a ‘tick-n-flick’ practice, which refers to writing or completing WHO SSC without performing safety assess-ment or check. The participants further indicated that there is non- adherence to WHO SSC because they do not know the importance of completing the checklist. This was evident in the direct comments from participants: “I believe that all members of the perioperative surgical team should attend an education program or awareness campaign about the signifi-cance of the WHO SSC, which includes a step-by-step implementation approach and clear roles and responsibilities” (Participant 5) This finding shows that the surgical team usually do not check all the items on the checklist but falsely complete the remaining items. The participants stated that not knowing the importance of applying WHO SSC by other team members hinder the adherence as some of the items are omitted as quoted below: “Surgeons confirm patients in the holding or reception area, but sign- in items are not confirmed during that same time”. “I do not think anesthetists are aware of the items that are specific to them, for sign out items, blood loss and specimen are the once we ask surgeons” (Partici-pant 5) “Most of anesthesiologists and surgeons consider WHO SSC to be a nursing practice. They don’t realize that it applies to all members of the peri‑operative surgical team. Some registered nurses are just doc-umenting this WHO SSC in the system, they are unaware of its signifi-cance” (Participant 12). This subtheme further revealed that pressure of documentation compliance instead of actual compliance has led to registered nurses who run the process of WHO SSC completion into performing tick and flick practice, the major issue was that if a system item was left blank, the system would not allow an incomplete checklist to be saved. The registered nurses reported that they complete items on the system, even if they were not called, because the system will fail and not save the entire items. One participant stated that: “This is a question they don’t want to hear. When we call out com-ponents of the checklist, we will ask certain questions while skipping others, however, in the system, we are obviously going to tick and save on all elements of WHO SSC in all stages”. “We do omit calling the items, but documentation will be complete in the system. We don’t ask about things like surgery duration and unanticipated blood loss in simple pe-diatric procedures during time out. We tick and save the items that we didn’t even call” (Participant 5). This finding shows that the surgical team usually do not check all the items on the checklist but falsely complete the remaining items. 3.2.2.Theme 2: Team factors The peri‑operative surgical team indicated that the attitudes of the team members contribute to not adhering to SSC. These were grouped into personal attitudes and uncertainty regarding who is responsible for leading the process. 3.2.2.2.Personal attitudes.The personal attitudes were expressed in terms of “surgical team absent at key times of WHO SSC completion”, “lack of commitment or interest in involved tasks from the surgical team members”, “poor or inadequate communication among the surgical team members” and “insecurity and resistance from other surgical team Table 1 Themes and subthemes. Themes Subthemes 1. Use of WHO SSC factors Checklist steps and uncertainty regarding the safe use of WHO SSC 2. Team factors Personal attitudes Uncertainty regarding who is responsible for leading the process. 3. Checklist items factors Most of the items are duplication of the existing checks. Completion of checklist items are repeating during periods of high workload. 4. Procedural factors Time constraints L.M. Manamela et al.
members”. Regarding surgical team absent at key times of WHO SSC completion, some of the peri‑operative surgical team members raised the concern of incomplete team during sign in and sign out phases, specifically consultant surgeons who they mentioned as the most responsible sur-gical team member. Others indicated that mostly during sign in and sign out phase the peri‑operative surgical team is incomplete thus leading to non-adherence. Participants stated: “During sign-in, only the anesthesiologist is present. The most responsible physician, the consultant surgeon, is usually unavailable during sign-in” (Participant 5). “One of the observations I’ve encountered throughout these phases of the surgical safety checklist is that not all members of the peri‑op-erative surgical team are present in the operating theatres. Surgeons are not there during sign in” (Participant 8). In our study, the peri‑operative surgical team felt that during WHO SSC implementation, some members continued with other tasks, continued with conversations not related to the current checklist pro-cess, which indicated lack of interest as commented:” When we are conducting time out especially, the surgeons will begin talking and will not listen; even the anesthesia team will not listen at times” (Participant 6) The current study participants also find it very challenging when calling out and completing SSC because of poor communication among the team members. The participants highlighted that usually there is no response from a responsible person and the one doing call out feels like talking alone and stop calling out and just complete the checklist in silence. This was found to hinder adherence, because the completion process requires a team effort. One participant stated that: “Inside the operating theatres, peri‑operative surgical team does not engage verbally with the surgeon, anesthesiologist, nurses, or technol-ogist; they need to communicate to each other, creating a closed loop communication system. It seems registered nurses prefer writing to verbalizing; they prefer to document elements of WHO SSC checklist on the system. Communication is also influenced by language barrier” (Participant 12). Some of our study participants reported that some surgical team members show signs of insecurities and resistance when it comes to the completion of SSC as stated below: “Some peri‑operative surgical team members are ignorant and refuse to follow the process of SSC, I think they are resisting because of insecurities” (Participant 9). Resistance limits the success to adhere or full completion of the checklist. 3.2.2.3.Uncertainty regarding who is responsible for leading the process. When it comes to uncertainty regarding who is responsible for leading the process, the findings revealed that non-adherence in executing the WHO SSC was related to not knowing the roles and responsibilities of each surgical team member during the implementation. It was clear from the surgical team members that there are some doubts as to who was supposed to be involved in some elements of the surgical safety checklist such as verification of patient’s identification, others indicated lack of uniformity which causes uncertainty during the surgery checklist call out as quoted below: “Now, let’s look at the sign in part. So, who does the patient iden-tification confirmation procedure, the anesthesiologist, the surgeon, or the scrub nurse”? (Participant 4) “Registered nurses always take over if there is no one taking his or her responsibility in the reading and application of WHO SSC” (Partic-ipant 5). “Registered nurses are always taking a lead in the whole process, I think it is their responsibility, but some will refuse to lead but still ask you to do it, I’m confused” (Participant 3). Being uncertainty on when to perform or/and by who will lead to non-adherence. 3.2.3.Theme 3 Checklist items factors The participants indicated that the checklist items have some con-straints that affect the surgical team members from adhering to the process. They verbalized that most of the items are duplication of the existing checks and completion is during periods of high workload. 3.2.3.4.Most of the items are duplication of the existing checks.The peri‑operative surgical team complained that the items in the checklist are duplicate of other activities that are conducted whenever the patient is coming for a surgical procedure. For example, checking patient identity, sterility indicator checks, surgical counts or confirming avail-ability of implants are carried out before the use of the checklist, as a standard operating procedure in the operating theatres. In their facility, an electronic system is used and easily shows when there is duplication. Therefore, they get bored and more often ignore those items during checklist call out. The quotations below support this finding: “Items that are repeated we omit, we don’t ask about blood loss at sign-in because this is something, we usually ask about during time out” (Participant 10). “Time out elements are repeated and have previously been called out at sign in. Due to repetition, we already know responses to some of the questions. The number of time-out items should be decreased due to repetition” (Participant 12). Drawing from the data it was obvious that the use of the WHO SSC as a “check box” exercise appears to be facilitated by electronic recording in the current setting. 3.2.3.5.Completion of checklist items are repeating during periods of high workload.Participants also noted that beside repetition of some items, the completion of SSC is carried out during periods of high workload which makes it difficult for them to adhere to call out items that are a repetition. They indicated that routine tangible tasks repeat during sign in period, when the anesthetist team is busy attaching monitors, inserting intravenous cannulas for fluid and anesthetic agents, preparing the correct size endotracheal tubes, gas induction on restless and anxious pediatric patients without an intravenous line. These make it difficult for them to verify the patient’s identity again, because the anesthetic team identify them whilst in the ward and reception. The following quotations provide evidence that support the high workload clashing with the sign in phase: “During sign in, the anesthetist is busy preparing endotracheal tubes, inspecting the machine to optimize the patient before the surgery be-gins, alright. I’ve also seen that during this final time out, the surgeon and circulating nurse are still preoccupied with settling the drapes and other such tasks; this should not be the case” (Participant 2). “Signing in is difficult, circulating nurses are the ones who are really confirming patient identity, other members of the perioperative team are absent, and the anesthetists are busy preparing endotracheal tubes and medications for the patient. No one else participates” (Participant 9). The participants further, shared their frustrations with time out phase, which clashes with routine activities such as connecting surgical equipment and causing the surgical team not pay attention and engage during the surgical pause phase. The following quotations provide evi-dence that support the high workload clashing with time out phase: “Due to activities that conflict with calling time out, such as con-necting machine cables and tying assistant surgeons’ gowns, adherence is difficult with only two registered nurses in an operating theater” (Participant 11). “Everyone is busy during surgery checklist times; therefore, they don’t respond to issues that demand their response” (Participant 12). 3.2.4.Theme 4 procedural factors Procedures involved during the completion of SSC was revealed as one of the factors contributing to non-adherence. In our study, L.M. Manamela et al.
difficulties in completing SSC were verbalized and often indicated to be related to time constraints. Many participants highlighted that there is a lot of pressure on the team to complete the SSC given the activities and time needed to carry a surgical procedure. They also mentioned that the process delays a list of booked patients that awaits to be operated within the prescribed waiting time. 3.2.4.6.Time constraints.Time constraints was often indicated to be related to “length of the WHO SSC completion being too long due to time taken to review the SSC”, “delayed confirmation of booked surgeries on the system due to time taken to review the WHO SSC”, “difficulties of completing the WHO SSC during life threatening emergency proced-ures”, and “difficulties of completing WHO SSC during short and local surgery procedures” The participants verbalized that some peri‑operative surgical team members, surgeons to be specific, are impatient when it comes to duration of WHO SSC process. They stated that surgeons complain of a lengthy process in completing SSC and that it is a waste of time. The quotes below support this statement. “Some of the surgeons are unfamiliar with the checklist, while others regard it as a waste of time” (Participant 3). “We are occasionally yelling at them for taking too long to call all of the checklist items” (Participant 5). The participants in our study also indicated that their time is limited to complete the WHO SSC because they deal with delays in confirmation of booked surgeries on the system due to time taken by the anesthetists to review the booked patients. Participants 10 expressed herself as fol-lows: “Late confirmation of the patient on the system, as registered nurses cannot access WHO SSC unless the anesthesiologist has confirmed operation scheduling on best care, is another element contributing to non-adherence. At the end of the case actual checklist calls won’t match documentation time on the system.” In the selected facility the registered nurses’ access a surgery checklist on the system (computer) and the booking confirmation must be accepted first by the anesthetist, otherwise the WHO SSC process will be blocked. So if there is a delay in accepting the patient booking, automatically there will be a delay on checklist documentation, because a registered nurse will first remind the anesthesia team to accept the booking prior to completion of WHO SSC. Therefore, even if registered nurses call time out before skin incision, there would be a time gap and non-adherence between skin incision time, time out output recorded on the checklist. There was no literature related to this item as it was basically the selected hospital documentation process and operating theatres booking protocol. The peri‑operative surgical team in our study also indicated that they deal with difficulties in completing the WHO SSC during life threatening emergency procedures. They reported that life threatening emergency procedures does not allow them to waste time calling out WHO SSC as all the staff members are busy saving lives as stated by the following quotations: “In an emergency, everyone is focused on saving the patient’s life, there is no time to call out and complete the checklist” (Participant 2). “To be honest, in an emergency, it’s impossible to adhere to elements on WHO SSC” (Participant 10). Some peri‑operative surgical team members indicated that they were omitting some items which they viewed as not relevant for local surgery procedures with a short duration. It was clearly indicated that the WHO made the checklist all-inclusive, even though some elements on the checklist were not suitable or relevant shorter and for local anesthesia surgery. The following participant’s quotations provided evidence that completion during short and local surgery procedures contributed to non-adherence: “One of the factors I can mention is short local anesthesia cases, because those cases last less than five minutes, but WHO SCC items are equivalent for short five-minute local cases and normal longer-duration cases like cesarian sections, so most of the items aren’t applicable for local surgery procedures where the anesthesiologist is not even present” (Participant 7). “It’s challenging to complete items on the checklist for a six-minute duration procedure, because the checking will take more time than a pro-cedure itself” (Participant 10). “For local surgery cases it’s impossible to call out all items” (Participant 11). 4.Discussion This study explored the factors that contribute to non-adherence of the peri‑operative surgical team to WHO surgical safety checklist in the Kingdom of Saudi Arabia. Factors such as the use of WHO SSC, team, checklist items and procedures involved came up strongly during the discussions. 5.Use of WHO SSC factors The use of WHO SSC factors was based on the checklist steps and uncertainty regarding the safe use of WHO SSC. The expressions on this factors included knowledge and importance of applying WHO SSC. Failure to understand the importance of WHO SSC was regarded as a contributory to non-adherence. This finding is in line with the study that investigated the impact of the WHO SSC on patient safety, in which the participants indicated that patients can be harmed if safety items on the WHO SSC are neglected 13. A study conducted on procedures for developing evidence-informed performance checklists for improving early childhood intervention practices, suggested that a safety checklist should be cost effective 14. The same authors, added that desired out-comes such as patient satisfaction, prevention of surgical patient’s harm and protection from “never events should be produced. Of more concern from the data was that some of the peri‑operative surgical team members perform tick and flick practice. This finding confirms the findings of the previous study, in which the team was found unreliable with the implementation of WHO SSC 9. It is known that some of the surgical team complete some items without calling and checking 15. The other study discovered that some checklist items were completed in the recovery room 7. Thus, WHO SSC is frequently ‘ticked and flicked’ by surgical personnel, rather than being read aloud and completed by the entire team as intended in many contexts. In one observational study it was revealed that all WHO SSC elements were signed off as indicating that every item had been completed, however no item demonstrated 100 percent compliance on observation in all hospitals 7. Fourcade et al. 8 confirm that WHO SSC are marked off even though they weren’t checked merely to comply with the management audit. These practices result with false documentation and hindering ad-herences to completion of the checklist. The authors of the current study argue that the unreliability is related to poor understanding and importance of completing WHO SSC. According to the study conducted on surgical safety checklists in a non-native English-speaking country, unfamiliar with the WHO SSC’s content and execution by certain peri‑operative surgical team members was found to be a big obstacle to non-adherence by 16. Therefore, when surgical team have knowledge and understanding of the surgical safety checklists, will complete it correctly to diminish chances of errors that could lead to patient’s harm. The electronic recording of WHO SSC in the current study seems to contribute to non-adherence. In the same line, it is worth noting that hospitals that use the electronic format have some of the best record- based compliance but also have some of the lowest direct-observation compliance 17. 6.Team factors Regarding team factors, personal attitudes and uncertainty regarding who is responsible for leading the process hinder the adherence. Absent L.M. Manamela et al.
of some team members during the call out of the checklist were found to be common. The study conducted in the surgical department of the University Hospital of Basel, Switzerland, revealed that surgeons are often not in the room during some part of WHO SSC 18. Thus, “sign in” is usually not verbally validated because other members of the surgical team were not present or were engaged in other high-priority activities. The sign-out phase is also not fully integrated into existing operating theater procedures at times, because the operating surgeon leave the operating theater prior to closing the wound as the assistant surgeon are left to complete surgical wound closure in layers 19. Other participants reported that some team members will be present but continue with other activities that are not related to the call out of the checklist. The similar challenge was identified during an evaluation of the barriers and facilitators toward implementation of the WHO SSC across hospitals in England 19. It is worrying if WHO SSC is inadequately conducted or disregarded because it poses a risk to patient safety and collaborative teamwork 20. Ineffective communication was one of the reasons contributing to non-adherence to surgical safety checklist in a Swiss academic center 18. This miscommunication is responsible for intraoperative and post-operative complications. Implying that challenges in communication are often related to poor or inadequate adherence to the completion of WHO SSC. Therefore, to increase participation in SCC items, there’s a need to target professional communication practices and work processes such as workflow which curtail team members’ ability to participate. The par-ticipants in our study identified refusals and resistance by other team members to be a hinder to WHO SSC. The previous study also listed them as the barriers to WHO SSC implementation and compliance 16. The study on adherence to the WHO surgical safety checklist: an observa-tional study in a Swiss academic center, revealed that active resistance or passive resistance are most commonly among senior surgeons and/or anesthesiologists 18. It seems as if the peri‑operative surgical team members are also uncertain on when to perform sign out (before the end of the case vs before the patient is removed from the OR) and who owns sign-out (surgeons versus nurses). This finding was also reported by the study conducted in France 8. It is assumed that the cause is lack of delegation of the most responsible peri‑operative surgical team member to announce the checklist 11. The other reason might be that when other team members showed less interest in the completion, nurses take it upon themselves to execute all components of WHO SSC to prevent adverse events and errors 20. 7.Checklist items factors The items listed on the checklist were found to be a cause of non- adherence to completion. Duplication with existing checks was found to be the most commonly occurring obstacle to adherence. In France cancer centers it was discovered that some of the items on the checklist are repeating themselves 8. It should be noted that the items listed in the checklist contributes towards reduction of errors that might occur dur-ing the perioperative care. However, reducing duplication and customizing the checklist according to the surgical situation or specific surgical procedures is needed to improve adherence in completing the items. In Thai hospitals it was found that everyone become too busy during surgical checklist items call out times, as such misses real-time checking, either before or after surgery 15. Moreover, it is reported that lack of a streamlined and cohesive approach to completion of SSC make the adoption difficult in the operating theater. 8.Procedural factors In this study, it was apparent that the participants also believed that a procedure of completing WHO SSC makes them not to adhere, especially because of time constraint. Just like the findings of this study, many consider the WHO SSC a waste of time, and find some other ways to bypass the steps. Fourcade et al. 8 findings are of the opinion that the WHO SSC had no added value and took too long to complete while there are a lot of tasks to still do. This might be one of the reasons, the peri‑operative surgical team members find the procedure of completing WHO SSC to be a factor influencing non-adherence to completion 18. It is worrying that during urgent or emergent surgeries, the surgical team members are often reluctant to complete the surgical safety checklist items or omit some items, even though there is a greater requirement for safety checks 8. While some elements of the checklist were considered irrelevant or unsuitable for the shorter surgical procedures 8. The au-thors of the current paper are of the opinion that the checklist should be altered to suit short, local and life-threatening surgical cases to enhance adherence. 9.Implications The findings of this study provided apparent evidence to why the perioperative surgical team is not adhering to the execution of WHO SSC. The findings of this study imply that some of the surgical team members do not adhere to WHO SSC. The study is clearly showing the consequences of insufficient execution of WHO SSC that need to be addressed at the institutional level. The findings may be used to influ-ence policies and operating standards in the operating theatres to reduce the mishaps. Furthermore, the provided information may be used to develop and improve operating theater practice related to WHO SSC implementation and improving patient safety. 10.Limitations There are several limitations in this study, especially regarding recruitment and sample. The first author recruited the participants from her own workplace through open invitation, email, and passing by re-minders. Therefore, it was possible that the participants may have found it difficult to refuse her request. However, the participation was voluntary and could have withdrawn from the participation at any time. The participants were also provided with an information leaflet explaining all the details regarding ethical implications and signed an informed consent prior to participation. The study was only conducted in one operating theater of a private, secondary hospital in the Kingdom of Saudi Arabia. The study was limited to registered peri‑operative nurses, qualified surgeons and anesthetists working in the operating theater. Surgical assistants, Anesthesia technologists and operating theater managers were excluded. However, the selected sample is directly involved in the completion of WHO SSC providing in-depth data that increases the credibility of the study. Therefore, despite the limitations, the study does provide essential data for understanding critical aspects of the research field with significant implications for clinical practice and future research activities. 11.Recommendations The authors are of the opinion that to improve adherence to WHO SSC, the managerial teams at all levels should support the surgical team by developing effective patient safety policies. In addition, the surgical team should be continuously mentored, supervised, evaluated and merited. The support should be at managerial and team level, and educational support is also recommended. 11.1.Managerial level support Management at all levels should be involved in improving the adherence to WHO SSC and monitor team performance, because orga-nizational support promotes and facilitate adherence to the policies. The hospital managers should meet with the patient safety coordinators, departmental heads and operating theater coordinators regularly to L.M. Manamela et al.
discuss and emphasize the importance of WHO SSC. Directors of surgical departments should also meet with peri‑operative surgical team mem-bers to emphasize the importance of adhering to the WHO SSC. Joint performance improvement project on the WHO SSC would be ideal, involving surgeons, anesthesiologists, anesthesia technologist, regis-tered nurses, and an operating theater leadership to enhance adherence. This implies that management interest and participation in the use of WHO SSC will increase compliance and adherence by all members of the peri-operative surgical team, while supportive supervision and moni-toring motivate the staff members and improves performance. 11.2.Team level support Teamwork establishes a system of balance towards reducing surgical errors and improves patient safety. Therefore, peri-operative surgical team members should encourage each other to work as a team and improve WHO SSC adherence. It is essential for the peri‑operative sur-gical team to support and work harmoniously with each other as the findings showed the difficulties experienced when following the steps of the checklist. Poor teamwork threatens patient safety during surgery. The whole sign-in, time-out, and sign-out process should be a team effort for better administration of all the checklist components. It is, therefore, crucial for all members to be present inside the operating theatres throughout the administration of WHO SSC, so that all the vital infor-mation towards safe surgery will be shared to all the involved team members. 11.3.Educational support Peri-operative surgical team members need to know the importance of WHO SSC to aid proper compliance and adherence. Educational strategies, which include, formal and informal on continuous basis can lead to increased knowledge and understanding the importance of administrating and applying WHO SSC during surgical procedures. Therefore, there is a strong need to better education and training on completion of WHO SSC by all peri-operative surgical team members. New employees, including students and interns must undergo WHO SSC training in stages to familiarize them with the checklist items. Training should be ongoing and include seminars and in-service training. To raise awareness poster should be displayed on the corridors and in each theater. The more the surgical team is aware of the risks associated with lack of adherence to WHO SSC, they will modify their attitude and become more responsible. Proper education of peri-operative surgical team members on WHO SSC is also integral to improve their awareness about, and adherence with any other principles in operating theatres. Therefore, additional training on WHO SSC at individual and team levels are important for the peri-operative surgical team to successful complete the checklist. 12.Conclusion This paper presented the factors that contribute to non-adherence of peri‑operative surgical team and recommended ways to improve adherence of WHO SSC in the Kingdom of Saudi Arabia. The factors contributing to non-adherence of the peri-operative surgical team to WHO surgical safety checklist in the selected hospital was identified through sign-in, time-out, and sign-out. According to the findings, mostly during sign-in phase the peri‑operative surgical team is incom-plete, specifically surgeons thus leading to non-adherence. It was also identified that the registered nurses are always the one leading in con-firming the patient identity during sign-in and if they are not leading it will not be done. While most of the time surgeons confirm patients in the reception area alone without completing the checklist and / absent during the process. The surgical team also found to be too busy with other vital activities and do not pay much attention to the questions required for the completion of sign-in period which influence non- adherence. Non-adherence related to time-out is also directed towards clashing with routine activities, in which the team pay more attention to. The participants in our study also indicated that the time-out activ-ities are unnecessarily too long and some items are repeating, moreover, they skip them. In addition, there are delays caused by the anesthesia team who do not accept the booking of patients on the computer system after confirming their suitability for surgery. In the selected hospital surgeons seem to be not adhering to the WHO SSC as most of the time they are talking amongst themselves during the period and in a hurry to start the surgical procedure. During sign-out, the surgeons do not participate, because they will leave the operating theater immediately after the operation, while the surgeon assistant finishes up the wound closure, and will not be accountable for the questions asked during sign- out phase. The several identified factors associated with the non-adherence encourage further research efforts in peri-operative surgical team and patient’s safety during surgery. It is also anticipated that the findings of this study will assist the selected hospital and other hospitals who are experiencing similar challenges to improve the adherence to WHO SSC completion. CRediT authorship contribution statement Lorraine Motlalepula Manamela: Conceptualization, Data cura-tion, Formal analysis, Investigation, Methodology, Resources, Valida-tion, Writing – original draft, Writing – review & editing. Melitah Molatelo Rasweswe: Supervision, Conceptualization, Formal analysis, Data curation, Methodology, Resources, Validation, Writing – original draft, Writing – review & editing. Ramadimetja Shirley Mooa: Vali-dation, Supervision, Writing – review & editing. Declaration of Competing Interest None. Acknowledgements The authors wish to acknowledge the peri‑operative surgical team who participated in the study. Funding No funding was received References 1Haynes AB, Weiser TG, Berry WR, et al. Safe Surgery Saves Lives Study Group: a surgical safety checklist to reduce morbidity and mortality in a global population. New Engl J Med. 2009;360:491–509. 2Anwer M, Manzoor S, Muneer N, Qureshi S. Compliance and effectiveness of WHO Surgical Safety Check list: a JPMC audit. Pak J Med Sci. 2016;32(4):831–835. https:// doi.org/10.12669/pjms.324.9884. 3Ramsay G, Haynes AB, Lipsitz SR, et al. Reducing surgical mortality in Scotland by use of the WHO Surgical Safety Checklist. 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