Background: The WHO surgical safety checklist (SSC) has been globally implemented including Thailand to reduce preventable surgical adverse events. However, it has no national data of SSC implementation in Thailand. This study aimed to evaluate the use, the compliance, the satisfaction, the obstacle, and problem solving of SSC implementation.
Methods: A mixed methods, quantitative and qualitative methods, descriptive study was conducted between November 2013 and February 2015 in 61 hospitals in Thailand, 46 government hospitals and 15 private hospitals. A questionnaire eliciting on demographics, the use, the compliance, the effectiveness, the satisfaction, the obstacle, and problem solving of SSC implementation was distributed to surgical personnel for collecting quantitative data. Three focus group discussions with 39 operating room nurses and in-depth interviews with 50 surgical personnel (10 surgeons, 10 anesthesiologists, 10 operating room nurses, 10 nurse anesthetists, and 10 surgical ward nurses) were performed for gathering qualitative information. Data were analyzed using descriptive statistics and content analysis.
Results: A total 2,024 surgical personnel were recruited. The three majorities were operating room nurses (55.04 %), nurse anesthetists (23.42%) and surgeons (12.94%). Of these, 10.09% was hospital administrators. The means of the use and the compliance with the SSC were 86.98 % (+19.09) and 84.44 % (+20.59), respectively. Overall, surgical personnel satisfied with the SSC at a high level (mean=3.79+0.71). The three most satisfactions were the benefit to the patient (mean 4.11+0.69), the benefit to the organization (mean 4.05+0.68), and affected to reduce the adverse event (mean 4.02+0.69). Overall, the obstacle for implementation of SSC was rated as moderate (mean=2.52+0.99). In the sign in period, overall item was rated as weak (mean=2.41). The two major obstacles were rated as moderate including a surgical site mark (mean=2.67) and evaluating the risk of > 500 ml blood loss (7 ml/kg) in children (mean=2.62). In the time out period, overall item was rated as weak (mean=2.50). The two major obstacles were rated as moderate including the surgeon anticipated critical events (mean=2.77) and all team members have introduced themselves by name and roles (mean=2.72). In the sign out period, overall item was rated as weak (mean=2.34). The two major obstacles were rated as moderate including the surgeon, anesthetist and nurses anticipated the key concerns for recovery and management of the patient (mean=2.56) and nurse verbally confirmed the name of the procedure (mean=2.51).
The qualitative data documented that the major obstacles of SSC implementation included no policy, unclear or impractical policy, poor teamwork or individual cooperation (especially at the beginning), unsuccessful communication to surgeon, and inadequate personnel. Further obstacles were some surgical personnel lack of true understanding about the contents of SSC and process of implementation caused uncertainty, incorrectly, or ineffectively implementation. The SSC was completed before or after the surgery which was not “real time” and the processes were “cut short” to get it done quickly. Additional obstacle was patients’ tiredness of being asked and investigated for many times.
The study suggested that the strategies to improve SSC implementation were the policy enforcement and support from national level (Ministry of Public Health, Ministry of Education) and hospital level. The SSC should be added in the training curriculum for surgeon, anesthesiologist, nurse anesthetist, and operating room nurse, and added in the key performance indicators. Other key strategies were mandatory implementation with clear operational guideline, using collaborative approach, using modern media and technology, performing public relations and campaign, training using role play and station-based model, modifying the SSC suitable for hospital’s context, giving reward, imposing some rules seriously, monitoring and feedback, and patient-involvement. Potential promotion factors were enforcement SSC implementation to the residency training center by the Royal College of Surgeons of Thailand, recognizing surgical adverse events, providing information about the benefit of SSC implementation, and building self-awareness of surgical team.
Conclusion: The use and the compliance with WHO SSC in Thailand was high. The satisfaction with WHO SSC was high. The obstacles of SSC implementation were rated as weak to moderate. These included both structures and processes. The policy enforcement and support, collaborative approach, training with practice, imposing some rules, giving reward, monitoring and feedback, acknowledgement the benefit of the SSC, self-awareness of surgical team, and patient-involvement may lead to improve the use and the compliance with WHO SSC in Thailand.