The Operating Theatre Journal May 2022

Human Factors – Safer Surgery Checklist
Across our next three publications, there is going to be an article on
Human Factors in the operating theatre, regarding the use of the
safer surgery checklist. The article is written by Mr Nigel Roberts, who
is the Theatre Lead at the University Hospitals of Derby and Burton.
Nigel is currently undertaking a PhD at the University of Derby and is
researching the safer surgery checklist. The article will be published
over three issues and consist of the following, May 2022- Introduction
and Background, June 2022 - Literature Review and July 2022 - NHS
England Audit findings.
Author:
Nigel Roberts, MSc, BA (Hons), PGR Student, ODP
University Hospitals of Derby and Burton
Keywords:
Human Factors, World Health Organisation (WHO) Surgical Safety
Checklist, Culture, Leadership, Situational Awareness, Teamwork,
Staff attitude, communication.
Abstract:
This paper is part of a literature review undertaken by the lead author
towards the award of Doctor of Philosophy (PhD).
This paper addresses information raised as part of an audit of NHS
hospital operating theatres in England.
Introduction and background context:
This review is looking at human factors and behaviours that are
specific towards the use of the safer surgical checklist and the current
three intra-operative never events. As a healthcare industry, working
with technological advances, we remain obsessed with the financial
and technical aspects of delivering tangible care. There is substantial
literature stating that the non-technical skills such as communication,
teamwork and leadership are major contributors to adverse events
in healthcare globally. Weiser and Haynes (2018, p. 927) commented
that ‘the checklist is a difficult safety tool to implement, with
problems in application, fidelity and execution’. Prior to the launch
of the Safer Surgery Checklist (SSC) research by Lingard et al. (2002),
Greenberg et al. (2007), Rosenstein and Regehr (2006) and Kennedy
et al. (2009, all cited in Robertson et al., 2014, p. 1) stated that ‘the
evaluation of team non-technical skills has become important in
research on surgical safety because of the evidence that teamwork
glitches, communication failures, cultural and hierarchal barriers
contribute to safety failure’. Rydenfalt et al. (2013, p. 185) study in
Sweden suggested that the checklist is designed to reduce risk, so the
understanding of ‘risk’ among those conducting the checklist may be
important to implementation. From a safety perspective the checklist
can be regarded as a barrier or a defence against failure. The World
Health Organisation Surgical Safety Checklist was introduced in
June 2008 at the PanAmerican Health Organisations headquarters in
Washington D.C., USA. (Weiser and Haynes, 2018)
To ‘err is human’ (Kohn, Corrigan and Donaldson, 2000) is acceptable,
and we should expect systematic errors, but we must ensure
the systems and processes in place are not fallible, and blame is
not apportioned. The Joint Commission (2017, cited in Nelson,
2017) which is an American organisation, classes the three intraoperative
‘never events’ as ‘Sentinel’. Sentinel events are patient
safety incidents that result in death, permanent harm, (or) severe
temporary harm and intervention is required to sustain life. The
Healthcare Safety Investigation Branch (2021) class ‘never events’ as
patient safety incidents that are defined as being wholly preventable.
They are considered wholly preventable because guidance or safety
recommendations are in place at a national level and should have
been implemented by all providers in the healthcare system. The
NHS (2018) class ‘never events’ as serious incidents that are entirely
preventable because guidance or safety recommendations providing
strong systemic protective barriers are available at a national level
and should have been implemented by all healthcare providers. So
why are ‘never events’ still occurring, is it solely down to human
factors? Could the problem actually be at source, the World Health
Organisation (WHO)? They stated that the ‘safer surgery checklist
is not a regulatory device or a component of official policy; it is
intended as a tool for use by clinicians interested in improving the
safety of their operations and reducing unnecessary surgical deaths
and complications’ (2012, cited in Nugent et al., 2013, p. 172).
Bosk et al. (2009, cited in Nugent et al., 2013) stated that it is
important to explain why and how a checklist should be implemented.
Deploying a checklist without building an appreciation for how and
why it works ignores critical sociocultural dimensions of how safe
care is achieved. This is partially supported a few years later by
Levy et al. (2012, cited in Devcich et al., 2016) as they suggested
that disengaged or cynical use of the safer surgical checklist may
actually be counterproductive. Levy et al. (2012, cited in Weiser
and Haynes, 2018) claimed that studies have demonstrated that the
checklist concept may encourage box-ticking without true fidelity to
the communication and process assurance aspects of the checklist.
This leads one to ask, why healthcare workers would disengage from a
process that studies have shown to reduce morbidity, mortality, postoperative
complications, infections and length of stay, to name a few.
Haugen et al. (2013, cited in Nelson 2017) say that the safer surgery
checklist does not resolve every safety issue, it does help to encourage
interaction among team members and promote a culture of safety.
This finding was supported by Nugent et al. (2013) study in Ireland, as
they reported that the safer surgery checklist encouraged a greater
degree of teamwork and a better interdisciplinary communication,
thus a reduction in adverse events.
Weaver et al. (2013, cited in Nelson, 2017) found that promoting
a culture of safety required strong leadership, teamwork, and a
willingness to change behaviours. Ragusa et al. (2016, cited in Nelson,
2017) study suggest that the safer surgery checklist improves patient
safety, it has not been proven to reduce wrong-site surgery. This
finding is still true today, as the NHS’s biggest ‘never event’ is wrong
site surgery (see section 2.7.1, p. 87) The Care Quality Commission
(2018, cited in Koleva, p. 256) stated that ‘never events are wholly
preventable and despite considerable patient safety efforts, serious
preventable surgical events continue to occur’.
Have we, the NHS and other global health care providers, created
a culture of accepted ‘normal behaviour’ and become resistant to
change. Is it that simple, is it just a cultural issue? Along side this
literature review, an audit across NHS England operating theatres will
occur, to ascertain staffs opinion at the ‘coal-face’ as to which nontechnical
skills/ human factors are still causing barriers to the use and
completion of the WHO surgical safety checklist. Afterall, Lingard et
al. (2008, cited in Fowler, 2013) state that the safer surgical checklist
on average only takes between one and four minutes to complete.
The operating theatre is a complex, busy, ever-changing environment,
where complex procedures needing considerable interaction amongst
the multidisciplinary team members take place. Shouhed et al. (2012,
cited in Koleva, 2020, p. 256) supports this as they stated, ‘the
operating theatres are complicated, stressful environments, equipped
with a wide range of hi-tech equipment and multidisciplinary staff’.
Moppett and Moppett (2016, cited in Ferorelli, 2022) say that the
current three intraoperative never events all depend on non-technical
aspects to get them correct. Panagioti et al., (2019, cited in Ferorelli,
2020, p. 2) claims that ‘around one in twenty patients are exposed
to preventable harm, 10% of which are reported in surgery’. Bogner
(2003) and Uramatsu et al., (2008, cited in Kalantari et al., 2021, p. 1)
state that ‘defects in non-technical aspects of performance increase
the chance of medical errors that are important causes of ‘never
events’’. Brunckhorst et al. (2017) and Collins et al. (2018, cited in
Kalantari et al., 2021, p. 1) say that the ‘non-technical skills include
social and cognitive abilities such as leadership, decision making, and
teamwork’. Carayon et al. (2014, cited in Kalantari et al., 2021) found
that human factors are core elements of patient safety improvements.
The Joint Commission (2015, cited in Kalantari et al., 2021) state that
the non-technical skills are component features of human factors.
Fabri and Zayas-Castro (2008), De Silva et al. (2013) and Wahr et al.
(2013, all cited in Koleva, 2020) all support the previous study findings
as they found that data from across the world shows that known
sources of error in operating theatres comprise of human fallibility,
miscommunication, lack of collaboration of team activity, humantechnology
interaction and poor management of the environment.
Kar, Papaspyros and Prasad (2015) study at the Royal Infirmary of
Edinburgh, cardiac theatres initially identified a lack of leadership and
teamwork in relation to the safer surgery checklist. They concluded
that human factors and teamwork training would be of benefit.
Continued on next page
Find out more 02921 680068 • e-mail admin@lawrand.com Issue 380 May 2022 13