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Erschienen in: World Journal of Surgery 8/2016

Open Access 28.04.2016 | Scientific Review

Postoperative Adverse Events Inconsistently Improved by the World Health Organization Surgical Safety Checklist: A Systematic Literature Review of 25 Studies

verfasst von: Elzerie de Jager, Chloe McKenna, Lynne Bartlett, Ronny Gunnarsson, Yik-Hong Ho

Erschienen in: World Journal of Surgery | Ausgabe 8/2016

Abstract

Background

The World Health Organization Surgical Safety Checklist (SSC) has been widely implemented in an effort to decrease surgical adverse events.

Method

This systematic literature review examined the effects of the SSC on postoperative outcomes. The review included 25 studies: two randomised controlled trials, 13 prospective and ten retrospective cohort trials. A meta-analysis was not conducted as combining observational studies of heterogeneous quality may be highly biased.

Results

The quality of the studies was largely suboptimal; only four studies had a concurrent control group, many studies were underpowered to examine specific postoperative outcomes and teamwork-training initiatives were often combined with the implementation of the checklist, confounding the results. The effects of the checklist were largely inconsistent. Postoperative complications were examined in 20 studies; complication rates significantly decreased in ten and increased in one. Eighteen studies examined postoperative mortality. Rates significantly decreased in four and increased in one. Postoperative mortality rates were not significantly decreased in any studies in developed nations, whereas they were significantly decreased in 75 % of studies conducted in developing nations.

Conclusions

The checklist may be associated with a decrease in surgical adverse events and this effect seems to be greater in developing nations. With the observed incongruence between specific postoperative outcomes and the overall poor study designs, it is possible that many of the positive changes associated with the use of the checklist were due to temporal changes, confounding factors and publication bias.

Introduction

One in 25 people undergo a surgical procedure every year [1]. Surgery is intended to save lives but unsafe surgical care can cause substantial harm; complications after inpatient operations occur in 25 % of patients and the reported crude mortality rate after major surgery is 0.5–5 % [2]. At least half of the cases in which surgery leads to harm are considered preventable [3]. Most surgical errors are caused by failures of non-technical skills such as communication, leadership and teamwork [4].
In 2008 the World Health Organization (WHO) developed a surgical safety checklist (SSC), in an attempt to minimise surgical adverse events [2]. The three phase 19-item checklist comprises various perioperative items directly targeted to assure execution of specific safety measures. The mechanism by which the checklist is said to improve surgical outcomes involves both direct and indirect means. Direct factors such as ensuring timely administration of prophylactic antibiotics may result in decreased rates of postoperative infections. Indirectly, the checklist is reported to increase the ‘safety culture’ in operating theatres and thus decrease non-technical surgical errors, resulting in a positive effect on all postoperative adverse events [59].
The checklist has been implemented as a standard of care into thousands of operating rooms worldwide as it is relatively easy to implement and unlikely to cause harm [10]. However, there is emerging evidence that for the checklist to be effective it requires a deliberate implementation process, continual monitoring and learning within frontline teams [11]. It is thus necessary to determine the effects of the checklist on postoperative outcomes to validate this continued effort. Furthermore, the checklist may become a routine activity of checking of boxes without actually driving behavioural change thus giving staff a false sense of security [1214].
Previous literature reviews have all suggested an apparent reduction in postoperative adverse events following the implementation of the checklist; however, all have concluded that higher quality studies are needed [1521]. Since the last published review, many large-scale studies have been published, including two randomised controlled trials (RCT) [2226]. Hence there is a need for an updated systematic review of the SSC. This systematic literature review examines the effects of the implementation of the WHO SSC on postoperative complications and mortality.

Methods

Protocol and registration

This systematic review is reported using the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines [27]. The review focuses on studies with primary quantitative data on the effects of the implementation of the WHO SSC on postoperative adverse events. The review was registered in the PROSPERO database, reference number: CRD42015024373.

Search criteria

A literature search of publications published from 2007 to June 2015 was conducted. Two investigators (EdJ and CM) searched MEDLINE, CINAHL, Scopus, Cochrane and ProQuest databases using the following search strategy; (WHO OR World Health Organisation OR World Health Organization) AND checklist AND (surgery OR surgical OR operative). The date last searched was June 4th 2015. Reference lists of relevant studies were searched by hand to identify additional publications. Authors of select studies were contacted to find additional information. The two investigators screened the titles and abstracts of potential studies, and full text potential studies were reviewed where necessary.

Eligibility criteria

Included studies incorporated a population of patients undergoing surgical procedures, in which the WHO SSC was implemented, compared to a control group where the checklist was not used or a control group with low compliance to the checklist. The outcomes were quantitative data on postoperative complications or mortality, however defined by the authors. Postoperative pain, urinary tract infections, nausea and vomiting were not considered significant postoperative complications.
Studies were excluded if they were not written in English or did not use the WHO SSC or an adaption of the WHO SSC. Studies were also excluded if the intervention concurrently consisted of a bundle of action such that the sole effect of the safety checklist could not be isolated, for example, where pulse oximetry was introduced alongside the implementation of the checklist.

Data extraction and analysis

The two investigators used a standardised data sheet to extract data from included studies. Data were extracted for study setting, design and duration, sample size, surgical procedures included and quantitative patient outcomes. Postoperative complication and mortality rates were extracted. Two authors independently performed data extraction and a third review author adjudicated any discrepancies (LB). The included studies were deemed unsuitable for Meta-analysis since they were too heterogeneous and mostly observational studies.

Quality

Randomised controlled trials were assessed using the Cochrane RevMan Risk of Bias tool [28]. Non-randomised controlled trials were assessed using a modified version of the previously validated Methodological Index for Non-Randomised Studies (MINORS) [29]. The original 12-item index had two items removed by authors, item six and seven. A similar modification has previously been reported [16]. These items relate to an adequate duration of follow-up after the implementation of the checklist. There is currently no consensus about the most appropriate duration of follow-up. There may be an increased emphasis of surgical safety and higher levels of compliance to checklist use early after the intervention, resulting in falsely encouraging outcomes in studies with short follow-up periods. Alternatively, the checklist-induced cultural change may take time to develop and thus studies with a short follow-up period may not show the full effects of the checklists' use. As such, an appropriate length of follow-up could not be defined.

Results

Search results

Database and reference list searches yielded 509 articles, of which full text of 109 articles were examined. Based on the inclusion and exclusion criteria, 25 studies were included (Fig. 1; Table 1) [27].
Table 1
Characteristics of included studies (statistically significant results bolded)
Author/year/country (developed nations bolded)
Study Design
Length of review
Sample size
Type of procedures included/excluded
Type of Intervention
Outcome measures
Pre/post,  %, P value, [% change if significant]
Askarian et al. (2011), Iran [43]
Prospective cohort
Pre: 3 months
Post: 3 months
294
Elective general surgery > 16 years
 
Total complications
Pre: 22.9, Post: 10 p = 0.03 [-56]
SSI
Pre: 10.4, Post: 5.3 p = 0.1
Pneumonia
Pre: 7.6, Post: 3.3 p = 0.1
Acute renal failure
Pre: 4.9, Post: 2.0 p = 0.17
Baradaran et al. (2015), Iran [44]
Prospective cohort
NR
200
Elective general surgery > 16 years/end stage & immunocompromised patients
 
Any complication
Pre: 30, Post 12 p = 0.002 [-60]
Unplanned readmission to the OT
Pre: 9, Post: 2, p = 0.03 [-67]
SSI
Pre: 13, Post: 7 p = 0.157
Pneumonia
Pre: 8, Post: 3 p = 0.121
Biskup et al. (2015), United states of America [25]
Retrospective cohort
Pre: 39 months
Post: 39 months
4476
Plastic surgery
 
Total complications
Pre: 5.95, Post: 5.75 p = 0.799
Mortality
Pre: 0.05, Post: 0.04 p = 0.549
Infection
Pre: 1.75, Post: 2.29 p = 0.206
Wound dehiscence
Pre: 1.20, Post: 1.47 p = 0.439
Respiratory failure
Pre: 0.09, Post: 0.04 p = 0.613
Pneumonia
Pre: 0.05, Post: 0 p = 0.484
Bliss et al. (2012), Unites states of America [33]
Pre: Retrospective historical control
Post: Prospective cohort
32 months
2398
Specific high risk electively scheduled procedures, > 18 years/traumatic injuries
Three session team training program
Any adverse event
Pre: 23.6, Post: 8.2 p = 0.000 [-65]
Infectious
Pre: 11.1, Post: 6.8 p = 0.514
Sepsis
Pre: 2.5, Post: 2.7 p = 0.355
Septic shock
Pre: 2.3, Post: 0 p = 0.411
SSI
Pre: 6.2, Post: 5.5 p = 0.845
Pneumonia
Pre: 2.4, Post: 0 p = 0.362
All pulmonary events
Pre: 6.1, Post: 0 p = 0.087
All cardiac events
Pre: 1.9, Post: 0 p = 0.124
Acute renal failure
Pre: 0.4, Post: 0 p = 0.045 [-100]
Bleeding
Pre: 6.1, Post: 2.7 p = 0.392
Surgical wound disruption
Pre: 0.5, Post: 0 p = 0.325
DVT/PE
Pre: 0.7, Post: 0 p = 0.074
Ventilator use > 48 h
Pre: 3, Post: 0 p = 0.311
Boaz et al. (2014), Israel [35]
Retrospective review
Pre: 6 months
Post: 6 months
760
Adult Orthopaedics
 
Mortality
Pre: 0.8, Post: 2.7 p = 0.049 [ +238]
Total complications
Pre 25.9 Post 18.9 p = 0.02 [-27]
Length of hospital stay
Pre: 7.3 Post 7.4 p = 0.132
Septic shock
Pre: 0, Post: 0.3 p = 0.316
SIRS
Pre 0.5, Post 0.3 p = 0.564
SSI
Pre: 3.2, Post: 2.1 p = 0.368
Post operative fever
Pre: 10.6, Post: 5.3 p = 0.008 [-50]
Wound infections at discharge
Pre: 0.3, Post: 2.4 p = 0.01 [+700]
Chaudhary et al. (2015), India [26]
Randomised control trial
13 months
700
Gastroenterology > 16 years
 
Mortality
Pre: 10, Post: 5.7 p = 0.004 [-43]
Complications per patient
Pre: 0.97, Post: 0.8 p = 0.06
High grade complications per patient
Pre: 0.33, Post: 0.23 p = 0.004 [-30]
Total complication rate
Pre: 52, Post: 46 p = 0.15
Sepsis
Pre: 30, Post: 26 p = 0.31
Wound related
Pre: 8.5, Post: 4.5 p = 0.04 [-47]
Respiratory complication
Pre: 3.7, Post: 4 p = 1
Cardiac complication
Pre: 2.5, Post: 3.4 p = 0.65
Renal complication
Pre: 2.2, Post: 0.5 p = 0.1
Abdominal complication
Pre: 28, Post: 19.7 p = 0.01 [-30]
Bleeding
Pre: 2.8, Post: 0.5 p = 0.03 [-82]
Length of hospital stay
Pre and Post = 9 days p = 0.54
Haughen et al. (2015), Norway [23]
Stepped wedge randomised control trial
10 months
5295
Cardiothoracic, neurosurgery, orthopaedic, general & urological
Educational program with standardised lectures and information materials.
Mortality
Pre: 1.6, Post: 1 p = 0.151
Any complication
Pre: 19.9, Post: 11.5 p = 0.001 [-42]
Unplanned readmission to theatre
Pre: 1.7, Post: 0.6 p < 0.001 [-65]
Infectious complications
Pre: 6, Post: 3.4 p < 0.001 [-43]
Sepsis
Pre: 0.6, Post: 0.3 p = 0.075
SSI
Pre: 2.2, Post: 1.5 p = 0.149
Pneumonia
Pre: 3.7, Post: 1.9 p < 0.001 [-48]
Respiratory complication
Pre: 6.4, Post: 3.2 p < 0.001 [-50]
Cardiac complication
Pre: 6.4, Post: 4.3 p < 0.004 [-33]
Bleeding
Pre: 2.3, Post: 1.2 p < 0.008 [-48]
Anaesthetic complication
Pre: 0.3, Post: 0.2 p = 0.772
Embolism
Pre: 0.5, Post: 0.2 p = 0.092
Hayes et al. (2009), Multinational [38]
Pre: Retrospective historical control
Post: Prospective cohort
Pre: 3 months
Post: 3 months
7688
 
Local study team introduced the checklist using lectures, written materials and direct guidance.
Total Mortality
Pre: 1.5, Post: 0.8 p = 0.003 [-47]
Any complication
Pre: 11, Post: 7 p < 0.001 [-36]
SSI
Pre: 6.2, Post: 3.4 p < 0.001 [-45]
Unplanned return to OT
Pre: 2.4, Post: 1.8 p = 0.047 [-25]
Pneumonia
Pre: 1.1, Post: 1.3 p = 0.46
India, United states of America, Tanzania, Canada, New Zealand
No statistically significant changes
Jordan
 
Mortality
Pre: 1, Post: 0 p < 0.05 [-100]
Any complication
Pre: 11.6, Post: 7 p < 0.05 [-40]
SSI
Pre: 4, Post: 2 p < 0.05 [-50]
Unplanned return to OT
Pre: 4.6, Post: 1.8 p < 0.05 [-61]
Pneumonia
Pre: 0.8, Post: 1.2 P > 0.05
Philippines
 
Mortality
Pre: 1.4, Post: 0 p < 0.05 [-100]
Any complication
Pre: 21.4, Post: 5.5 p < 0.05 [-74]
SSI
Pre: 20.5, Post: 3.6 p < 0.05 [-82]
Unplanned return to OT
Pre: 1.4, Post: 1.8 P > 0.05
Pneumonia
Pre: 0.3, Post: 0 P > 0.05
England
 
Mortality
Pre: 2.1, Post: 1.7 P > 0.05
Any complication
Pre: 12.4, Post: 8.0 p < 0.05 [-35]
SSI
Pre: 9.5, Post: 5.8 p < 0.05 [-38]
Unplanned return to OT
Pre: 1.3, Post: 0.2 p < 0.05 [-84]
Pneumonia
Pre: 1, Post: 1.7 p > 0.05
Jammer et al. (2015), 28 European nations [51]
Prospective cohort
7 days
45,591 from 426 sites
Non-cardiac surgery > 16 years
 
No clear relationship between patterns of checklist use and mortality rates in individual countries
 
Crude mortality
Pre: NR, Post: NR p = 0.002
→ Adjusting for confounders
p < 0.06
Lepatuma et al. (2013), Finland [36]
Pre: Retrospective historical control
Post: Prospective cohort
Pre: 6 wks
Post: 6 wks
150
Neurosurgery, > 18 years
 
Total complication
Pre: 58, Post: 46 p = 0.16
All unplanned readmissions (ICU, OT, hospital 30 days)
Pre: 25.3, Post: 10.4 p = 0.02 [-58]
Readmission to operating room
Pre: 19.3, Post: 9 p = 0.076
Infectious
Pre: 13.3, Post: 13.4 p = 0.94
SSI
Pre: 9.6, Post: 4.5 p = 0.347
Pneumonia
Pre: 4.8, Post: 3 p = 0.69
Bleeding
Pre: 14.5, Post: 11.9 p = 0.652
Wound dehiscence
Pre: 3.6, Post: 0 p = 0.254
DVT
Pre: 1.2, Post: 0 p = 1
Mechanical ventilation > 48 h
Pre: 10.8, Post: 7.5 p = 0.479
Wound combined
Pre: 19.3, Post: 7.5 p = 0.038 [−61]
Duration of hospital stay (Days)
Pre 6.65, Post 6.76 p = 0.46
Lubbeke et al. (2013), France [ 47 ]
Prospective cohort
Pre: 3 months
Post: 3 months immediate
3 months 1 year after
3 months 2 years after
2427
High risk surgical patients > 16 years, ASA 3-5/emergency, gynaecological & obstetric surgery, ambulatory surgery & minor urological surgery
 
Baseline to post combined
 
Unplanned return to OT
Pre: 7.4, Post: 6 RR = 0.82 CI(0.59-1.14)
Unplanned return to OT for SSI
Pre: 3, Post: 1.7 RR = 0.56 CI(0.32-1) [-43]
Unplanned readmission to ICU
Pre: 2.8, Post: 2.6 RR = 0.9 CI(0.52-1.55)
In hospital mortality
Pre: 4.3, Post: 5.9 RR = 1.44 CI(0.97-2.14)
Baseline to post period 1
 
Unplanned return to OT
Pre: 7.4, Post: 5.8 p = NR
Unplanned return to OT for SSI
Pre: 3, Post: 1.6 p = NR
Unplanned readmission to ICU
Pre: 2.8, Post: 3.1 p = NR
In hospital mortality
Pre: 4.3, Post: 7.4 p = NR
Baseline to post period 2
 
Unplanned return to OT
Pre: 7.4, Post: 6.3 p = NR
Unplanned return to OT for SSI
Pre: 3, Post: 1.6 p = NR
Unplanned readmission to ICU
Pre: 2.8, Post: 2.3 p = NR
In hospital mortality
Pre: 4.3, Post: 4.8 p = NR
Baseline to post period 3
 
Unplanned return to OT
Pre: 7.4, Post: 5.9 p = NR
Unplanned return to OT for SSI
Pre: 3, Post: 1.7 p = NR
Unplanned readmission to ICU
Pre: 2.8, Post: 2.5 p = NR
In hospital mortality
Pre: 4.3, Post: 5.6 p = NR
Mayer et al. (2015), United Kingdom [37]
Retrospective review
14 months
6714
General, urological, orthopaedic elective & emergency
>16 years
Examined checklist completion vs. not completing the checklist and linked this to postoperative outcomes
Mortality
Pre: 1.4, Post: 0.9 p = 0.67
Complication
Pre: 16.9, Post: 11.2 p < 0.01 [-33]
Morgan et al. (2015), United kingdom [39]
Retrospective review
Concurrent control group
Pre: 6 months
Post: 6 months
2352
Pre: vascular and general surgery
Post: Orthopaedic surgery
One day teamwork-training course, six weekly in service coaching
Complication rate
Pre: 21.5, Post: 26.8 p = 0.05 [+ 25] → in concurrent control group during this time period complication rates decreased (27.1 to 25.7)
Length of stay
Pre: 11.1, Post: 13.2 p = 0.0371 [+ 19]
Readmission rate
Pre: 13, Post: 11 p = 0.25
Morgan et al. (2015), United kingdom [40]
Retrospective review
Controlled interrupted time series
Concurrent control group
Pre: 6 months
Post: 6 months
2221
Elective orthopaedic surgery
Teamwork training, plus training and follow-up support in developing standardised operating procedures
Complication rate
Pre: 14, Post: 18 p = 0.33
Length of stay
Pre: 11, Post: 7.2 p = 0.372
Readmission rate
Pre: 13, Post: 11 p = 0.29
Nelson et al. (2014), United states [41]
Prospective cohort
3 months
NR
NR
 
Mortality
No change
Total complications
No change
Oszvald et al. (2012), Germany [52]
Retrospective cohort
Pre: 4  years
Post: 18 months
12,390
All neurosurgery cases
Improved compliance to advanced checklist modified to suit local needs and addition of checklist in emergency settings
Number of errors (wrong sided)
Pre: 0.03, Post: 0 p = 0.74
Prakash et al. (2014), India [45]
Prospective cohort Concurrent cohort comparison
NR
152
General, obstetrics and gynaecology
 
Mortality
Pre: 1.38, Post: 0 p < 0.05 [-100]
Total AE
Pre: 15.27, Post: 5 p < 0.001 [-67]
SSI
Pre: 8.33, Post: 1.25 p < 0.001 [-85]
Wrong side surgery
Pre: 1.38, Post: 0 p < 0.05 [-100]
Excessive bleeding
Pre: 1.38, Post: 1.25 P > 0.05
Rodrigo-Rincon et al. (2015), Spain [24]
Retrospective cohort
Pre: 12 months
Post: 12 months
1602
Adults with a minimum hospital stay of 24 h
22 team training sessions
Mortality
Pre: 1.5, Post: 0.9 p = 0.356
Total complications
Pre: 18.1, Post: 16.2 p = 0.35
Reinterventions
Pre: 5.5, Post: 4.4 p = 0.356
Total complication rates non- elective
Pre: 31.8, Post: 20.4 p = 0.006 [-36]
Total complication rates elective
Pre: 12.9, Post 14.7 p = 0.42
Infections
Pre: 13.9, Post: 9.6 p = 0.037 [-31]
Sepsis
Pre: 2, Post: 0.5 p = 0.011 [-75]
SSI
Pre: 7.1, Post: 6 p = 0.419
Wound disruption
Pre: 4.7, Post: 6.5 p = 0.158
Pneumonia
Pre: 2.8, Post: 1.4 p = 0.077
PE
Pre: 0.1, Post: 0 p = 1
MI
Pre: 0, Post: 0.1 p = 0.317
Renal insufficiency
Pre: 0.05, Post: 0.01 p = 0.374
Bleeding
Pre: 1.5, Post: 1.7 p = 0.844
Thrombophlebitis
Pre: 0.5, Post: 0.4 p = 1
Ventilator use
Pre: 2.2, Post: 1.2 p = 0.181
Sewell et al. (2011), United Kingdom [6]
Pre: Retrospective historical control
Post: Prospective cohort
Pre: 4 months
Post: 5 months
965
Orthopaedic procedures
Training video, small and large group education sessions
Mortality
Pre: 1.9, Post: 1.6 P > 0.05
Total complications
Pre: 8.5, Post: 7.6 P > 0.05
Unplanned readmission to theatre
Pre: 1, Post: 1 P > 0.05
SSI
Pre: 4.4, Post: 3.5 P > 0.05
Tillman et al. (2013), United states [48]
Retrospective review
Pre: 1 yr
Post: 1 yr
6935
Cardiac, colorectal, general, gynaecological, orthopaedic, thoracic & vascular
Multidisciplinary team development, surgical team training, education, monitoring and coaching
Mortality
Pre: 0.9, Post: 1 p = 0.79
SSI
Pre: 3.13, Post: 2.96 p = 0.72
Colorectal SSI
Pre: 24.1, Post: 11.5 p < 0.05 [-52]
Orthopaedic SSI
Pre: 1.7, Post: 0.7 p = 0.06
Cardiac SSI
Pre: 7.4, Post: 13.9 p = 0.22
General SSI
Pre: 6.2, Post: 6.1 p = 0.92
Gynaecology SSI
Pre: 2.1, Post: 2.7 p = 0.77
Thoracic SSI
Pre: 2.4, Post: 7 p = 0.62
Vascular SSI
Pre: 2.5, Post: 4.7 p = 0.50
Urbach et al. (2014), Canada [22]
Retrospective cohort
Pre: 3 months
Post: 3 months
215,741 in 101 hospitals
All surgical procedures
Some hospitals used specific intervention or educational programs for the checklist implementation
Mortality
Pre: 0.71, Post: 0.65 p = 0.07
Total complications
Pre: 3.86, Post: 3.82 p = 0.53
Length of stay (days)
Pre: 5.11, Post: 5.07 p = 0.003 [-1]
Readmission to theatre
Pre: 1.94, Post: 1.78 p = 0.001 [-8]
Readmission to hospital within 30 days
Pre: 3.11, Post: 3.14 p = 0.76
ED visits in 30 days
Pre: 10.44, Post: 10.55 p = 0.37
Emergency procedure mortality
Pre: 4.51, Post 4.12 p = 0.11
Sepsis
Pre: 0.1, Post: 0.09 p = 0.73
Septic shock
Pre: 0.05 Post 0.05 p = 0.83
Shock
Pre: 0.07 Post 0.09 p = 0.26
SSI
Pre: 0.61, Post: 0.64 p = 0.30
Major wound disruption
Pre: 0.14, Post: 0.13 p = 0.61
Pneumonia
Pre: 0.31, Post: 0.31 p = 0.80
Acute renal failure
Pre: 0.1, Post: 0.13 p = 0.08
Bleeding
Pre: 0.64, Post: 0.63 p = 0.76
DVT
Pre: 0.03, Post: 0.07 p < 0.001 [+ 133]
PE
Pre: 0.03, Post: 0.03 p = 0.58
MI
Pre: 0.29 Post: 0.29 p = 0.91
Ventilator use
Pre: 0.08, Post: 0.12 p = 0.007 [+ 50]
Van Klei et al. (2012), Netherlands [42]
Retrospective cohort
18 months
25,513
All adult patients that underwent a surgery
Team meeting, compliance monitored monthly
Crude mortality
Pre: 3.13, Post: 2.85 p = 0.19
Mortality adjusted for baseline differences
OR 0.85 CI (0.73-0.98)
Vats et al. (2010), United Kingdom [49]
Pre: Retrospective historical control
Post: Prospective cohort
6 months
729
Trauma & orthopaedic, gastrointestinal, gynaecology
Research team meetings with operating theatre staff and local supervision
Mortality
No significant change
Total complications
No significant change
Weissner et al. (2010), Multinational [50]
Pre: Retrospective historical control
Post: Prospective cohort
<12 months
1700
Emergency procedures
Local study team introduced the checklist to the operating room staff through lectures, written materials and direct mentoring
Mortality
Pre: 3.7, Post: 1.4 p = 0.0067 [-62]
Total complications
Pre: 18.4, Post: 11.7 p = 0.0001 [-36]
SSI
Pre: 11.2, Post: 6.6 p = 0.008 [-41]
Estimated blood loss > 500 mL
Pre: 20.2, Post: 13.2 p < 0.001 [-34]
Yuan et al. (2012), Liberia [46]
Prospective cohort
Pre: 2 months
Post: 2 months
481
>16 years surgical patients
Lectures, written materials, direct guidance, team meetings
Total
 
Mortality
Pre: 2.2, Post: 2.8 p = 0.334
Total complications
Pre: 32.9, Post: 19.1 p = 0.005 [-42]
SSI
Pre: 28.6, Post: 9.9 p = 0.001 [-65]
Site 1
 
Mortality
Pre: 0.9, Post: 4.6 p = 0.191
Total complications
Pre: 16.2, Post: 13.6 p = 0.488
SSI
Pre: 13.1, Post: 9.6 p = 0.506
Site 2
 
Mortality
Pre: 3.4, Post: 1.4 p = 0.909
Total complications
Pre: 50, Post: 23.2 p = 0.008
SSI
Pre: 43.4, Post: 10.1 p < 0.001 [-77]
Pre = before the intervention, Post = after the intervention, RR = adjusted risk ratio, CI = 95 % confidence interval, SSI = surgical site infection, UTI = urinary tract infection, DVT = deep vein thrombosis, PE = pulmonary embolism, ARF = Acute renal failure, NR = not reported, OT = operating theatre, ED = emergency department, ASA = American Society of Anaesthesiologists score

Quality assessment

Two studies were RCTs, 13 were prospective observational studies and 10 were retrospective cohort studies. The mean Cochrane RevMan score for the two RCTs was nine out of a possible 14. The mean score on the modified MINORS tool was 14 (SD 3.6) out of a possible 20. Each item assessed by these scores may not be equally important. Hence, we refrained from presenting a sum score for individual publications and instead demonstrate the individual components of the scores in a Cochrane risk of bias figure (Figs. 2, 3) [28]. Four studies had a concurrent control group; the remaining studies were largely a pre- and post-implementation group comparison. Several studies did not have adequately matched cohort groups, with differences in the emergency status of the surgery, surgical specialty and patient characteristics.
Many studies did not report doing a sample size calculation. Studies that did do a sample size calculation often calculated these to report significant total pooled complication rates rather than specific postoperative complications. This contributed to many studies being reported underpowered to reach statistical significance for specific postoperative outcomes.

Risk of bias of included studies

Some generalised potential sources of bias and confounding included that various implementation approaches were used; teamwork-training initiatives themselves may have confounded the post-checklist data [30, 31]. High levels of communication and collaboration are associated with overall lower rates of morbidity [32]. Bliss and colleagues reported a statistically significant decrease in postoperative complications from 23.9 to 15.9 % after three teamwork-training sessions; this was further reduced to 8.2 % after the checklist was adopted [33].
The WHO recommends that local stakeholders alter the checklists. Hence the specific checklists used often vary. This may impact rates of specific postoperative complications and make it difficult to compare studies. The definition of postoperative complications and specific postoperative outcomes also varied between studies making comparison between studies difficult.
Many studies used direct observation to evaluate compliance, potentially leading to a Hawthorne effect where non-technical skills such as communications and leadership increased with the intervention not because of the intervention.
Surgical adverse events rates are influenced by many factors; whilst studies attempted to adjust for known confounders it is likely that there are unknown confounding factors that were not adjusted for. Most of the reviewed studies did not have a concurrent control group and unknown confounding factors likely impacted the interpretation of their results. As the use of the checklist is seen as best practice, it may be unethical to withhold its use in a clinical setting. In addition to this when concurrent control groups are used the contamination effect must be considered, especially for indirect effects of the checklist such as enhanced leadership, teamwork and the resultant improvement in ‘safety culture’.

Two randomised controlled trials

Chaudhary et al. randomised 700 patients to checklist use or omission in a hospital in India. Patients were blinded to the study whilst the treating teams were not and as such contamination effects may significantly affect the study’s results. Mortality, bleeding, abdominal and wound-related complication rates decreased significantly with the use of the checklist. The total complication rates, number of complications per patient, length of hospital stay, rates of sepsis, respiratory, renal and cardiac complications did not change [26].
A larger stepped wedge cluster randomised control trial with a sample size of 4475 was conducted in two hospitals in Norway. In this study, the checklist intervention was sequentially rolled out across five surgical specialties in a randomised order. As such the cohorts were not adequately controlled; there was a discrepancy in surgical specialty and type of anaesthesia used between cohorts and the intervention group was more likely to undergo emergency surgery. In addition to this, 25.6 % of the procedures allocated to the intervention step were not compliant with the checklist and results of these surgeries were excluded. The reasons for non-compliance were not assessed and this is a likely source of bias. The rates of total complications, unplanned readmission to theatre, infectious complications, pneumonia, haemorrhage, respiratory and cardiac complications significantly decreased, whilst mortality, sepsis, surgical site infections and thromboembolic complications did not significantly change [23].
When results of the two randomised control trials were compared, the only outcome that was significantly decreased in both studies was postoperative bleeding rates.

Developed vs. developing countries

A sub-analysis was done whereby studies were divided into developing and developed nations as classified by the World Bank classification [34]. Multinational studies that did not differentiate between high- and low-income countries were not included in the sub-analysis. In developed countries, 36 % of studies (5 [23, 33, 3537] out of 14 studies [6, 2225, 33, 3542]) showed a significant decrease in total complication rates compared to 83 % of studies (5 [38, 4346] out of 6 studies [26, 38, 4346]) conducted in developing nations. Mortality was not decreased in any of the 13 studies in developed nations [6, 2225, 35, 37, 38, 41, 42, 4749], whereas it was decreased in 75 % of studies (3 [26, 38, 45] out of 4 studies [26, 38, 45, 46]) in developing nations. Two studies reported an increase in mortality or complications; both of these studies were in developed nations [35, 39]. Thus in reviewed studies, the effect of the checklist seems to be greater in developing nations.

Total complications

The total complication rate was reported in 20 studies [6, 2226, 33, 3541, 4346, 49, 50], ten reported significantly decreased rates (range 34–67 %) [23, 33, 35, 37, 38, 4346, 50] and one reported increased complication rates (25 %) [39].
Mortality rates were reported in 18 studies [6, 2226, 35, 37, 38, 41, 42, 4551]; four reported a significant decrease in rates (range 43–100 %) [26, 38, 45, 50], whilst one reported an increase following the implementation of the checklist (238 %) [35].
Length of admission was examined in four studies [22, 26, 39, 40]; one reported a statistically significant but clinically insignificant decrease in length of stay by 0.04 days (p = 0.003) [22].
Unplanned return to the operating room was examined in eight studies [6, 2224, 36, 38, 44, 47]; four found a significant decrease in rates (range 8–67 %) [22, 23, 38, 44].
Surgical site infections were examined by 14 studies [6, 2224, 33, 35, 36, 38, 4346, 48, 50], four showed a statistically significant decrease (range 41–85 %) [38, 45, 46, 50]. Wound dehiscence was examined by five studies; no significant changes were found [22, 24, 25, 33, 36]. Combined wound complications were examined by two studies; both found a decrease (46 and 61 %) [26, 36].

Haematological studies

Rates of deep vein thrombosis (DVT) and/or pulmonary embolism (PE) were examined by five studies [2224, 33, 36]; the only significant change was that one study reported an increase in DVT rates by 133 % [22].
Postoperative bleeding rates were examined by eight studies [2224, 26, 33, 36, 45, 50]; three found a significant decrease (range 34–82 %) [23, 26, 50].

Miscellaneous other

Total infection rates were examined in five studies [2325, 33, 36], rates decreased in two studies [23, 24]. Rates of sepsis were examined in six studies [2224, 26, 33, 35], rates decreased in one study [24]. Ten studies examined respiratory complications [2226, 33, 36, 38, 43, 44], one study found a decrease in rates of pneumonia and in total respiratory complication rates [23]. Another study found an increase in ventilation use [22]. Renal complications were examined in five studies [22, 24, 26, 33, 43], one found a decrease in acute renal failure [33], no other results reached significance. Cardiac complications were reported in five studies [2224, 26, 33], one found a significant decrease in total rates [23]. One study examined total abdominal complications, which showed a reduction in complication rates [26].

Wrong-sided surgery

Two studies reported rates of wrong-sided procedures [45, 52]. One study found a statistically significant decrease; one patient had a wrong-sided surgery before the implementation, and no patients after the checklist was implemented (1.38 to 0 %, p < 0.05) [45].

Studies with increased rates of adverse outcomes

Two studies showed an increase in postoperative complications and mortality after the implementation of the checklist. In both studies, the comparisons were unadjusted, precluding meaningful conclusions.
Morgan et al. examined the effect of checklist compliance improvement initiatives on surgical outcomes with using a concurrent control group for comparison. In the intervention group, postoperative complications significantly increased, whist in the concurrent control group complications decreased (21.5 to 26.8 and 27.1 to 25.7 %, p = 0.05). The study was limited by a small sample size which prevented risk adjustment for differing patient characteristics between the groups. Another limitation was that a direct observational model was used; this is vulnerable to the Hawthorne effect and contamination [39].
Boaz et al. conducted a retrospective review of surgical outcomes before and after implementation of the checklist. It included 760 orthopaedic surgery patients and found an increase in postoperative mortality (0.8 to 2.7 %, p = 0.049) following the checklists implementation. The study reported that the composite postoperative complication rates decreased (25.9 to 18.9 %, p = 0.02), this was not significant after controlling for confounding variables. The study's conclusion and discussion focussed on a significant decrease in postoperative fever after implementation of the checklist [35].

Discussion

A surgical safety initiative, which has been implemented into thousands of operating rooms around the world, in an attempt to decrease preventable postoperative complications, should have a strong body of evidence supporting its use. This systematic review found that the effects of the checklist on postoperative outcomes were inconsistent. There may be some benefit to the implementation of the WHO SSC, with this benefit appearing to be greater in developing countries.
There is a lack of significant evidence to explain this phenomenon; that the checklist is more beneficial in developing compared to developed nations. Contributing theories are largely speculative with a lack of significant evidence. Developing countries may have an inherently higher rate of baseline complications and thus have a larger latitude for improvement initiatives to have an effect. Another point to consider is that the checklist partially works by improving non-technical skills such as teamwork, leadership and communication. These factors have a large societal and cultural aspect which may differ between sites. It is also possible that facets of the checklist were already a standard of care in developed countries prior to adoption of the checklist, reducing the effects of the checklist.
Rates of surgical adverse event outcomes are not independent. Postoperative complication rates are associated with postoperative mortality rates [53]. The checklist aims to reduce preventable surgical error and should decrease rates of specific postoperative complications, total surgical complications and postoperative mortality. Outcomes such as the length of stay should also decrease, as these are indirect measures of the postoperative complication rates [54]. The reviewed literature did not show congruency amongst outcomes of surgical adverse event rates. For example, Chaudhary et al. reported that postoperative mortality reduced significantly (by 43 %), whilst there was no significant change in total postoperative complication rates [26]. This phenomenon was observed both within some studies, and when all significant results from the reviewed literature were compared.
An effective safety improvement initiative should have consistent effects on outcomes. The effects of the checklist were inconsistent; this was evident within multicentre studies where the effect of the checklist often varied dramatically between sites. For example, Hayes et al., found significant decreases in postoperative adverse event rates in three of eight sites; the remaining five sites did not have any significant changes in outcomes [38]. The reported benefits of the checklist were from pooled data of all sites. Similarly Urbach et al., examined the effects of the checklist at 101 hospitals, of these six had a significant decrease in adverse event rates, three had a significant increase in adverse event rates and 92 sites had no significant changes in outcomes [22]. Individual sites may not have been sufficiently powered to detect changes, leading to a type two error. Regardless of this factor the effect of the checklist on postoperative outcomes appears to be most variable.
Reviewed studies tended to report substantial improvements in complication rates (range 34–67 %), or show no significant change. Half of surgical complications are reported to be preventable [3]. Hence even if the checklist stopped all preventable errors, postoperative complications would only reduce by 50 %. A change larger than this is likely to have contributing confounding factors or be biased by a poor study design.
Another factor to consider is publication bias. An under-representation of studies showing negative or no effects is well documented; studies with results supporting a hypothesis have a 50 % higher likelihood of publication compared to studies with a negative or neutral outcome [55]. The focus on statistically significant findings was also observed within reviewed studies; with some authors emphasising specific postoperative outcomes that were improved by the checklist, neglecting to comment on the many outcomes that were not altered or increased with the use of the checklist [35].
The checklist may be too generalised as it is intended to be applied to all surgical disciplines. Some specialties have called for their own specific checklists to be created whilst others have proposed a checklist tailored to each specific operation [25, 5658]. Further studies are needed to determine the effects of specialty-wide surgical safety checklists.
Many of the studies excluded patients below the age of 16 or 18; there is thus a lack of literature reporting the effects of the checklist on a paediatric population. Younger patients may not be able to confirm identity, site or procedure and may lack the ability to give consent. Further studies on the effects of the checklist on a paediatric population are warranted.
A limitation of this review is that reported compliance to the checklist was not scrutinised. Measures of compliance are largely based on specific aspects of care embedded in the checklist. This may be an inappropriate measure of the ‘safety culture’, which the checklist is said to promote. Ticking all the boxes does not mean that the actions the checklist calls for have been completed. Some studies did not report compliance, when it was described there was marked variability in compliance between checklist items [16]. Many studies used data from administrative databases that may report higher rates of compliance than those reported by auditing observers [59, 60]. This heterogeneity makes it difficult to compare compliance rates between studies, and even more so to relate these to adverse event outcome measures in an attempt to draw any meaningful conclusions.
A further limitation is that a meta-analysis was not conducted. Combining observational studies of heterogeneous quality may be highly biased. Included studies had a very diverse patient population and sample size. One study had a larger sample size than all other studies combined, because of this results of a meta-analysis would invariably be skewed to this study’s outcomes.

Conclusion

The WHO SSC has been widely implemented in an attempt to decrease preventable postoperative complications. This systematic literature review examined the effects of the implementation of the WHO SSC on postoperative adverse events. The review included results of three times as many studies as previously reviewed. The effects of the checklist on postoperative outcomes were inconsistent. With the observed lack of congruency between specific postoperative outcomes and the widespread lack of concurrent control groups, it is possible that many of the positive changes of the checklist were due to temporal changes, rather than the checklist itself. This is likely compounded by publication bias where studies reporting insignificant results are less likely to be published. There may be some benefit to the implementation of the WHO SSC and the benefit appears to be larger in developing countries. Further studies are needed to support the implementation and continued use of the checklist in thousands of operating rooms around the world.

Acknowledgments

We thank Madeleine Nowak for reviewing the manuscript.
Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://​creativecommons.​org/​licenses/​by/​4.​0/​), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made.

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Literatur
1.
Zurück zum Zitat Weiser TG, Regenbogen SE, Thompson KD et al (2008) An estimation of the global volume of surgery: a modelling strategy based on available data. Lancet 372:139–144CrossRefPubMed Weiser TG, Regenbogen SE, Thompson KD et al (2008) An estimation of the global volume of surgery: a modelling strategy based on available data. Lancet 372:139–144CrossRefPubMed
3.
Zurück zum Zitat Kable AK, Gibberd RW, Spigelman AD (2002) Adverse events in surgical patients in Australia. International journal for quality in health care : journal of the International Society for Quality in Health Care/ISQua 14:269–276CrossRef Kable AK, Gibberd RW, Spigelman AD (2002) Adverse events in surgical patients in Australia. International journal for quality in health care : journal of the International Society for Quality in Health Care/ISQua 14:269–276CrossRef
4.
Zurück zum Zitat Alnaib M, Al Samaraee A, Bhattacharya V (2012) The WHO surgical safety checklist. J Perioper Pract 22:289–292PubMed Alnaib M, Al Samaraee A, Bhattacharya V (2012) The WHO surgical safety checklist. J Perioper Pract 22:289–292PubMed
5.
Zurück zum Zitat Böhmer AB, Wappler F, Tinschmann T et al (2012) The implementation of a perioperative checklist increases patients perioperative safety and staff satisfaction. Acta Anaesthesiol Scand 56:332–338CrossRefPubMed Böhmer AB, Wappler F, Tinschmann T et al (2012) The implementation of a perioperative checklist increases patients perioperative safety and staff satisfaction. Acta Anaesthesiol Scand 56:332–338CrossRefPubMed
6.
Zurück zum Zitat Sewell M, Adebibe M, Jayakumar P et al (2011) Use of the WHO surgical safety checklist in trauma and orthopaedic patients. Int Orthop 35:897–901CrossRefPubMed Sewell M, Adebibe M, Jayakumar P et al (2011) Use of the WHO surgical safety checklist in trauma and orthopaedic patients. Int Orthop 35:897–901CrossRefPubMed
7.
Zurück zum Zitat Kearns RJ, Uppal V, Bonner J et al (2011) The introduction of a surgical safety checklist in a tertiary referral obstetric centre. BMJ Qual Saf 20:818–822CrossRefPubMed Kearns RJ, Uppal V, Bonner J et al (2011) The introduction of a surgical safety checklist in a tertiary referral obstetric centre. BMJ Qual Saf 20:818–822CrossRefPubMed
8.
Zurück zum Zitat Kawano T, Taniwaki M, Ogata K et al (2014) Improvement of teamwork and safety climate following implementation of the WHO surgical safety checklist at a university hospital in Japan. J Anesth 28:467–470CrossRefPubMed Kawano T, Taniwaki M, Ogata K et al (2014) Improvement of teamwork and safety climate following implementation of the WHO surgical safety checklist at a university hospital in Japan. J Anesth 28:467–470CrossRefPubMed
9.
Zurück zum Zitat Haynes AB, Weiser TG, Berry WR et al (2011) Changes in safety attitude and relationship to decreased postoperative morbidity and mortality following implementation of a checklist-based surgical safety intervention. BMJ Qual Saf 20:102–107CrossRefPubMed Haynes AB, Weiser TG, Berry WR et al (2011) Changes in safety attitude and relationship to decreased postoperative morbidity and mortality following implementation of a checklist-based surgical safety intervention. BMJ Qual Saf 20:102–107CrossRefPubMed
11.
Zurück zum Zitat Conley DM, Singer SJ, Edmondson L et al (2011) Effective surgical safety checklist implementation. J Am Coll Surg 212:873–879CrossRefPubMed Conley DM, Singer SJ, Edmondson L et al (2011) Effective surgical safety checklist implementation. J Am Coll Surg 212:873–879CrossRefPubMed
12.
Zurück zum Zitat Russ SJ, Sevdalis N, Moorthy K et al (2015) A qualitative evaluation of the barriers and facilitators toward implementation of the who surgical safety checklist across hospitals in England. Ann Surg 261:81–91CrossRefPubMed Russ SJ, Sevdalis N, Moorthy K et al (2015) A qualitative evaluation of the barriers and facilitators toward implementation of the who surgical safety checklist across hospitals in England. Ann Surg 261:81–91CrossRefPubMed
13.
Zurück zum Zitat Russ S, Rout S, Sevdalis N et al (2013) Do safety checklists improve teamwork and communication in the operating room? A systematic review. Ann Surg 258:856–871CrossRefPubMed Russ S, Rout S, Sevdalis N et al (2013) Do safety checklists improve teamwork and communication in the operating room? A systematic review. Ann Surg 258:856–871CrossRefPubMed
14.
Zurück zum Zitat Sarah Whyte LL, Sherry Espin G, Baker Ross, Bohnen John, Orser Beverley A, Doran Diane, Reznick Richard, Regehr Glenn (2008) Paradoxical effects of interprofessional briefings on OR team performance. Cogn Technol Work 10:287–294 Sarah Whyte LL, Sherry Espin G, Baker Ross, Bohnen John, Orser Beverley A, Doran Diane, Reznick Richard, Regehr Glenn (2008) Paradoxical effects of interprofessional briefings on OR team performance. Cogn Technol Work 10:287–294
15.
Zurück zum Zitat Bergs J, Hellings J, Cleemput I et al (2014) Systematic review and meta-analysis of the effect of the World Health Organization surgical safety checklist on postoperative complications. Br J Surg 101:150–158CrossRefPubMed Bergs J, Hellings J, Cleemput I et al (2014) Systematic review and meta-analysis of the effect of the World Health Organization surgical safety checklist on postoperative complications. Br J Surg 101:150–158CrossRefPubMed
16.
Zurück zum Zitat Gillespie BM, Chaboyer W, Thalib L et al (2014) Effect of using a safety checklist on patient complications after surgery: a systematic review and meta-analysis. Anesthesiology 120:1380–1389CrossRefPubMed Gillespie BM, Chaboyer W, Thalib L et al (2014) Effect of using a safety checklist on patient complications after surgery: a systematic review and meta-analysis. Anesthesiology 120:1380–1389CrossRefPubMed
17.
Zurück zum Zitat Lyons VE, Popejoy LL (2014) Meta-analysis of surgical safety checklist effects on teamwork, communication, morbidity, mortality, and safety. West J Nurs Res 36:245–261CrossRefPubMed Lyons VE, Popejoy LL (2014) Meta-analysis of surgical safety checklist effects on teamwork, communication, morbidity, mortality, and safety. West J Nurs Res 36:245–261CrossRefPubMed
18.
Zurück zum Zitat Patel J, Ahmed K, Guru KA et al (2014) An overview of the use and implementation of checklists in surgical specialities—a systematic review. Int J Surg 12:1317–1323CrossRefPubMed Patel J, Ahmed K, Guru KA et al (2014) An overview of the use and implementation of checklists in surgical specialities—a systematic review. Int J Surg 12:1317–1323CrossRefPubMed
19.
Zurück zum Zitat Tang R, Ranmuthugala G, Cunningham F (2014) Surgical safety checklists: a review. ANZ J Surg 84:148–154CrossRefPubMed Tang R, Ranmuthugala G, Cunningham F (2014) Surgical safety checklists: a review. ANZ J Surg 84:148–154CrossRefPubMed
20.
Zurück zum Zitat Thomassen O, Storesund A, Softeland E et al (2014) The effects of safety checklists in medicine: a systematic review. Acta Anaesthesiol Scand 58:5–18CrossRefPubMed Thomassen O, Storesund A, Softeland E et al (2014) The effects of safety checklists in medicine: a systematic review. Acta Anaesthesiol Scand 58:5–18CrossRefPubMed
21.
Zurück zum Zitat Treadwell JR, Lucas S, Tsou AY (2014) Surgical checklists: a systematic review of impacts and implementation. BMJ Qual Saf 23:299–318CrossRefPubMed Treadwell JR, Lucas S, Tsou AY (2014) Surgical checklists: a systematic review of impacts and implementation. BMJ Qual Saf 23:299–318CrossRefPubMed
22.
Zurück zum Zitat Urbach DR, Govindarajan A, Saskin R et al (2014) Introduction of surgical safety checklists in Ontario, Canada. N Engl J Med 370:1029–1038CrossRefPubMed Urbach DR, Govindarajan A, Saskin R et al (2014) Introduction of surgical safety checklists in Ontario, Canada. N Engl J Med 370:1029–1038CrossRefPubMed
23.
Zurück zum Zitat Haugen AS, Softeland E, Almeland SK et al (2015) Effect of the World Health Organization checklist on patient outcomes: a stepped wedge cluster randomized controlled trial. Ann Surg 261:821–828CrossRefPubMed Haugen AS, Softeland E, Almeland SK et al (2015) Effect of the World Health Organization checklist on patient outcomes: a stepped wedge cluster randomized controlled trial. Ann Surg 261:821–828CrossRefPubMed
24.
Zurück zum Zitat Rodrigo-Rincon I, Martin-Vizcaino MP, Tirapu-Leon B et al (2015) The effects of surgical checklists on morbidity and mortality: a pre- and post-intervention study. Acta Anaesthesiol Scand 59:205–214CrossRefPubMed Rodrigo-Rincon I, Martin-Vizcaino MP, Tirapu-Leon B et al (2015) The effects of surgical checklists on morbidity and mortality: a pre- and post-intervention study. Acta Anaesthesiol Scand 59:205–214CrossRefPubMed
25.
Zurück zum Zitat Biskup N, Workman AD, Kutzner E, et al. (2015) Perioperative safety in plastic surgery: is the World Health Organization Checklist useful in a broad practice? Ann Plast Surg Biskup N, Workman AD, Kutzner E, et al. (2015) Perioperative safety in plastic surgery: is the World Health Organization Checklist useful in a broad practice? Ann Plast Surg
26.
Zurück zum Zitat Chaudhary N, Varma V, Kapoor S et al (2015) Implementation of a surgical safety checklist and postoperative outcomes: a prospective randomized controlled study. Journal of Gastrointestinal Surgery 19:935–942CrossRefPubMed Chaudhary N, Varma V, Kapoor S et al (2015) Implementation of a surgical safety checklist and postoperative outcomes: a prospective randomized controlled study. Journal of Gastrointestinal Surgery 19:935–942CrossRefPubMed
27.
Zurück zum Zitat Moher D, Liberati A, Tetzlaff J et al (2009) Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. Ann Intern Med 151(264–269):W264CrossRef Moher D, Liberati A, Tetzlaff J et al (2009) Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. Ann Intern Med 151(264–269):W264CrossRef
28.
Zurück zum Zitat Higgins JP, Altman DG, Gotzsche PC et al (2011) The Cochrane Collaboration’s tool for assessing risk of bias in randomised trials. BMJ 343:d5928CrossRefPubMedPubMedCentral Higgins JP, Altman DG, Gotzsche PC et al (2011) The Cochrane Collaboration’s tool for assessing risk of bias in randomised trials. BMJ 343:d5928CrossRefPubMedPubMedCentral
29.
Zurück zum Zitat Slim K, Nini E, Forestier D et al (2003) Methodological index for non-randomized studies (minors): development and validation of a new instrument. ANZ J Surg 73:712–716CrossRefPubMed Slim K, Nini E, Forestier D et al (2003) Methodological index for non-randomized studies (minors): development and validation of a new instrument. ANZ J Surg 73:712–716CrossRefPubMed
30.
Zurück zum Zitat Catchpole K, Mishra A, Handa A et al (2008) Teamwork and error in the operating room: analysis of skills and roles. Ann Surg 247:699–706CrossRefPubMed Catchpole K, Mishra A, Handa A et al (2008) Teamwork and error in the operating room: analysis of skills and roles. Ann Surg 247:699–706CrossRefPubMed
31.
Zurück zum Zitat Wiegmann DA, ElBardissi AW, Dearani JA et al (2007) Disruptions in surgical flow and their relationship to surgical errors: an exploratory investigation. Surgery 142:658–665CrossRefPubMed Wiegmann DA, ElBardissi AW, Dearani JA et al (2007) Disruptions in surgical flow and their relationship to surgical errors: an exploratory investigation. Surgery 142:658–665CrossRefPubMed
32.
Zurück zum Zitat Davenport DL, Henderson WG, Mosca CL et al (2007) Risk-adjusted morbidity in teaching hospitals correlates with reported levels of communication and collaboration on surgical teams but not with scale measures of teamwork climate, safety climate, or working conditions. J Am Coll Surg 205:778–784CrossRefPubMed Davenport DL, Henderson WG, Mosca CL et al (2007) Risk-adjusted morbidity in teaching hospitals correlates with reported levels of communication and collaboration on surgical teams but not with scale measures of teamwork climate, safety climate, or working conditions. J Am Coll Surg 205:778–784CrossRefPubMed
33.
Zurück zum Zitat Bliss LA, Ross-Richardson CB, Sanzari LJ et al (2012) Thirty-day outcomes support implementation of a surgical safety checklist. J Am Coll Surg 215:766–776CrossRefPubMed Bliss LA, Ross-Richardson CB, Sanzari LJ et al (2012) Thirty-day outcomes support implementation of a surgical safety checklist. J Am Coll Surg 215:766–776CrossRefPubMed
35.
Zurück zum Zitat Boaz M, Bermant A, Ezri T et al (2014) Effect of surgical safety checklist implementation on the occurrence of postoperative complications in orthopedic patients. Israel Med Assoc J 16:20–25 Boaz M, Bermant A, Ezri T et al (2014) Effect of surgical safety checklist implementation on the occurrence of postoperative complications in orthopedic patients. Israel Med Assoc J 16:20–25
36.
Zurück zum Zitat Lepänluoma M, Takala R, Kotkansalo A et al (2014) Surgical safety checklist is associated with improved operating room safety culture, reduced wound complications, and unplanned readmissions in a pilot study in neurosurgery. Scand J Surg 103:66–72CrossRefPubMed Lepänluoma M, Takala R, Kotkansalo A et al (2014) Surgical safety checklist is associated with improved operating room safety culture, reduced wound complications, and unplanned readmissions in a pilot study in neurosurgery. Scand J Surg 103:66–72CrossRefPubMed
37.
Zurück zum Zitat Mayer EK, Sevdalis N, Rout S, et al. (2015) Surgical Checklist Implementation Project: The Impact of Variable WHO Checklist Compliance on Risk-adjusted Clinical Outcomes After National Implementation: A Longitudinal Study. Ann Surg Mayer EK, Sevdalis N, Rout S, et al. (2015) Surgical Checklist Implementation Project: The Impact of Variable WHO Checklist Compliance on Risk-adjusted Clinical Outcomes After National Implementation: A Longitudinal Study. Ann Surg
38.
Zurück zum Zitat Haynes AB, Weiser TG, Berry WR et al (2009) A surgical safety checklist to reduce morbidity and mortality in a global population. The New England journal of medicine 360:491–499CrossRefPubMed Haynes AB, Weiser TG, Berry WR et al (2009) A surgical safety checklist to reduce morbidity and mortality in a global population. The New England journal of medicine 360:491–499CrossRefPubMed
39.
Zurück zum Zitat Morgan L, Hadi M, Pickering S, et al. (2015) The effect of teamwork training on team performance and clinical outcome in elective orthopaedic surgery: A controlled interrupted time series study. BMJ Open 5 Morgan L, Hadi M, Pickering S, et al. (2015) The effect of teamwork training on team performance and clinical outcome in elective orthopaedic surgery: A controlled interrupted time series study. BMJ Open 5
40.
Zurück zum Zitat Morgan L, Pickering SP, Hadi M et al (2015) A combined teamwork training and work standardisation intervention in operating theatres: controlled interrupted time series study. BMJ Qual Saf 24:111–119CrossRefPubMed Morgan L, Pickering SP, Hadi M et al (2015) A combined teamwork training and work standardisation intervention in operating theatres: controlled interrupted time series study. BMJ Qual Saf 24:111–119CrossRefPubMed
41.
Zurück zum Zitat Nelson MF, Merriman CS, Magnusson PT et al (2014) Creating a physician-led quality imperative. Am J Med Qual 29:508–516CrossRefPubMed Nelson MF, Merriman CS, Magnusson PT et al (2014) Creating a physician-led quality imperative. Am J Med Qual 29:508–516CrossRefPubMed
42.
Zurück zum Zitat van Klei WA, Hoff RG, van Aarnhem EE et al (2012) Effects of the introduction of the WHO “Surgical Safety Checklist” on in-hospital mortality: a cohort study. Ann Surg 255:44–49CrossRefPubMed van Klei WA, Hoff RG, van Aarnhem EE et al (2012) Effects of the introduction of the WHO “Surgical Safety Checklist” on in-hospital mortality: a cohort study. Ann Surg 255:44–49CrossRefPubMed
43.
Zurück zum Zitat Askarian M, Kouchak F, Palenik CJ (2011) Effect of surgical safety checklists on postoperative morbidity and mortality rates, Shiraz, Faghihy hospital, a 1-year study. Qual Manag Health Care 20:293–297CrossRefPubMed Askarian M, Kouchak F, Palenik CJ (2011) Effect of surgical safety checklists on postoperative morbidity and mortality rates, Shiraz, Faghihy hospital, a 1-year study. Qual Manag Health Care 20:293–297CrossRefPubMed
44.
Zurück zum Zitat Baradaran Binazir M, Alizadeh M, Jabbari Bayrami H et al (2015) The effect of a modified world health organization surgical safety checklist on postoperative complications in a tertiary hospital in iran. Iran J Public Health 44:292–294PubMedPubMedCentral Baradaran Binazir M, Alizadeh M, Jabbari Bayrami H et al (2015) The effect of a modified world health organization surgical safety checklist on postoperative complications in a tertiary hospital in iran. Iran J Public Health 44:292–294PubMedPubMedCentral
45.
Zurück zum Zitat Prakash P, Baduni N, Sanwal MK, Sinha SR, Shekhar C (2014) Effect of World Health Organization surgical safety checklist on patient outcomes in a Tertiary Care Hospital of Delhi. Int Med J 21:376–378 Prakash P, Baduni N, Sanwal MK, Sinha SR, Shekhar C (2014) Effect of World Health Organization surgical safety checklist on patient outcomes in a Tertiary Care Hospital of Delhi. Int Med J 21:376–378
46.
Zurück zum Zitat Yuan CT, Walsh D, Tomarken JL et al (2012) Incorporating the World Health Organization Surgical Safety Checklist into practice at two hospitals in Liberia. Joint Commission J Qual Patient Saf 38:254–260 Yuan CT, Walsh D, Tomarken JL et al (2012) Incorporating the World Health Organization Surgical Safety Checklist into practice at two hospitals in Liberia. Joint Commission J Qual Patient Saf 38:254–260
47.
Zurück zum Zitat Lubbeke A, Hovaguimian F, Wickboldt N et al (2013) Effectiveness of the surgical safety checklist in a high standard care environment. Med Care 51:425–429CrossRefPubMed Lubbeke A, Hovaguimian F, Wickboldt N et al (2013) Effectiveness of the surgical safety checklist in a high standard care environment. Med Care 51:425–429CrossRefPubMed
48.
Zurück zum Zitat Tillman M, Wehbe-Janek H, Hodges B et al (2013) Surgical care improvement project and surgical site infections: can integration in the surgical safety checklist improve quality performance and clinical outcomes? J Surg Res 184:150–156CrossRefPubMed Tillman M, Wehbe-Janek H, Hodges B et al (2013) Surgical care improvement project and surgical site infections: can integration in the surgical safety checklist improve quality performance and clinical outcomes? J Surg Res 184:150–156CrossRefPubMed
49.
Zurück zum Zitat Vats A, Vincent CA, Nagpal K et al (2010) Practical challenges of introducing WHO surgical checklist: UK pilot experience. BMJ 340:133–135CrossRef Vats A, Vincent CA, Nagpal K et al (2010) Practical challenges of introducing WHO surgical checklist: UK pilot experience. BMJ 340:133–135CrossRef
50.
Zurück zum Zitat Weiser TG, Haynes AB, Dziekan G et al (2010) Effect of a 19-item surgical safety checklist during urgent operations in a global patient population. Ann Surg 251:976–980CrossRefPubMed Weiser TG, Haynes AB, Dziekan G et al (2010) Effect of a 19-item surgical safety checklist during urgent operations in a global patient population. Ann Surg 251:976–980CrossRefPubMed
51.
Zurück zum Zitat Jammer I, Ahmad T, Aldecoa C et al (2015) Point prevalence of surgical checklist use in Europe: relationship with hospital mortality. Br J Anaesth 114:801–807CrossRefPubMed Jammer I, Ahmad T, Aldecoa C et al (2015) Point prevalence of surgical checklist use in Europe: relationship with hospital mortality. Br J Anaesth 114:801–807CrossRefPubMed
52.
Zurück zum Zitat Oszvald A, Vatter H, Byhahn C et al (2012) “Team time-out” and surgical safety-experiences in 12,390 neurosurgical patients. Neurosurg Focus 33:E6CrossRefPubMed Oszvald A, Vatter H, Byhahn C et al (2012) “Team time-out” and surgical safety-experiences in 12,390 neurosurgical patients. Neurosurg Focus 33:E6CrossRefPubMed
53.
Zurück zum Zitat Borgi J, Rubinfeld I, Ritz J et al (2013) The differential effects of intermediate complications with postoperative mortality. Am Surg 79:261–266PubMed Borgi J, Rubinfeld I, Ritz J et al (2013) The differential effects of intermediate complications with postoperative mortality. Am Surg 79:261–266PubMed
54.
Zurück zum Zitat Khan NA, Quan H, Bugar JM et al (2006) Association of postoperative complications with hospital costs and length of stay in a tertiary care center. J Gen Intern Med 21:177–180CrossRefPubMedPubMedCentral Khan NA, Quan H, Bugar JM et al (2006) Association of postoperative complications with hospital costs and length of stay in a tertiary care center. J Gen Intern Med 21:177–180CrossRefPubMedPubMedCentral
55.
Zurück zum Zitat Krzyzanowska MK, Pintilie M, Tannock IF (2003) Factors associated with failure to publish large randomized trials presented at an oncology meeting. JAMA 290:495–501CrossRefPubMed Krzyzanowska MK, Pintilie M, Tannock IF (2003) Factors associated with failure to publish large randomized trials presented at an oncology meeting. JAMA 290:495–501CrossRefPubMed
56.
Zurück zum Zitat Helmiö P, Takala A, Aaltonen LM et al (2012) WHO Surgical Safety Checklist in otorhinolaryngology-head and neck surgery: specialty-related aspects of check items. Acta Otolaryngol 132:1334–1341CrossRefPubMed Helmiö P, Takala A, Aaltonen LM et al (2012) WHO Surgical Safety Checklist in otorhinolaryngology-head and neck surgery: specialty-related aspects of check items. Acta Otolaryngol 132:1334–1341CrossRefPubMed
57.
Zurück zum Zitat Kelly SP, Steeples LR, Smith R et al (2013) Surgical checklist for cataract surgery: progress with the initiative by the Royal College of Ophthalmologists to improve patient safety. Eye (Basingstoke) 27:878–882 Kelly SP, Steeples LR, Smith R et al (2013) Surgical checklist for cataract surgery: progress with the initiative by the Royal College of Ophthalmologists to improve patient safety. Eye (Basingstoke) 27:878–882
58.
Zurück zum Zitat Joshi S, Gorin MA, Ayyathurai R et al (2012) Development of a surgical safety checklist for the performance of radical nephrectomy and tumor thrombectomy. Patient Saf Surg 6:27CrossRefPubMedPubMedCentral Joshi S, Gorin MA, Ayyathurai R et al (2012) Development of a surgical safety checklist for the performance of radical nephrectomy and tumor thrombectomy. Patient Saf Surg 6:27CrossRefPubMedPubMedCentral
59.
Zurück zum Zitat Levy SM, Senter CE, Hawkins RB et al (2012) Implementing a surgical checklist: more than checking a box. Surgery 152:331–336CrossRefPubMed Levy SM, Senter CE, Hawkins RB et al (2012) Implementing a surgical checklist: more than checking a box. Surgery 152:331–336CrossRefPubMed
60.
Zurück zum Zitat Rydenfalt C, Johansson G, Odenrick P et al (2013) Compliance with the WHO Surgical Safety Checklist: deviations and possible improvements. Int J Qual Health Care 25:182–187CrossRefPubMed Rydenfalt C, Johansson G, Odenrick P et al (2013) Compliance with the WHO Surgical Safety Checklist: deviations and possible improvements. Int J Qual Health Care 25:182–187CrossRefPubMed
Metadaten
Titel
Postoperative Adverse Events Inconsistently Improved by the World Health Organization Surgical Safety Checklist: A Systematic Literature Review of 25 Studies
verfasst von
Elzerie de Jager
Chloe McKenna
Lynne Bartlett
Ronny Gunnarsson
Yik-Hong Ho
Publikationsdatum
28.04.2016
Verlag
Springer International Publishing
Erschienen in
World Journal of Surgery / Ausgabe 8/2016
Print ISSN: 0364-2313
Elektronische ISSN: 1432-2323
DOI
https://doi.org/10.1007/s00268-016-3519-9

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