Surgical checklist: Seeking the Involvement of Professionals and Patients


Surgical checklist: Seeking the Involvement of Professionals and Patients

INTRODUCTION Surgical procedures are a very important part of the healthcare activity of a hospital, and, therefore, their quality and safety are a m

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Surgical procedures are a very important part of the healthcare activity of a hospital, and, therefore, their quality and safety are a matter of common concern to all healthcare systems. In 2004 the World Health Organization (WHO) created the World Alliance for Patient Safety to promote awareness and political commitment to improve health care safety. A fundamental element of the Alliance’s Alliance’s work is the formulation of global challenges for patient safety, which is why in 2008, it promoted its “Second global challenge for patient safety: safe surgery saves lives.” The initiative proposed the implementation of a documentary verification instrument: the Surgical Verification List (LVQ), which will help to ensure compliance with basic safety standards in surgical procedures, will act as a barrier to adverse incidents, and will prove the good practice of the professionals involved (1). Shortly after, in 2010, the Ministry of Health published the Clinical Practice Guide for Surgical Patient Safety, which assessed the use of the list with a low-quality level of evidence and strong recommendation (2).

In this sense, the European Network for Patient Safety and Healthcare Quality (Paz) is a project co-financed by the European Commission within the Public Health Program that aims to facilitate the exchange of experiences between the member states of the European Union that participate in the implementation of safe practices, including safe surgery. Spain participates as an active partner and coordinator from the General Sub-Directorate for Quality and Cohesion of the Ministry of Health, Social Services, and Equality.

The Reina Sofía de Murcia General University Hospital, attached to the Paz project, is a second-level hospital that serves a health area with a population of close to 200,000 inhabitants and has 12 operating rooms with an effective average occupancy time of over 89% in major surgery. Our experience with the implementation of the LVQ was presented at the European Conference on Patient Safety: Implementation of safe practices within the framework of the Paz collaborative action held in October 2015 in Madrid and was well received by experts. We present a work that, despite not being a directly extrapolated study, analyzes the current situation of many health services and the possible factors associated with the failure of the implementation of the checklist,


General: Improve adherence to the surgical checklist. Claim the support of professionals and patients

Specific: To evaluate the perception of LVQ in the surgical area, to identify the barriers that hinder its implementation, and to establish a permanent, collaborative, and stable network of work around the quality and safety of the surgical patient.


The target population to which the experience was directed were professionals from the surgical area, doctors, and nurses from all surgical specialties of our hospital (General Surgery Instruments, traumatology, gynecology, urology, dermatology, ophthalmology, maxillofacial surgery, and otorhinolaryngology) and anesthesia. In the same way, activities were developed aimed at patients undergoing scheduled and emergency operations, with or without hospital admission.

As a consequence of our adherence to the project, an Action Plan was drawn up, adapting the LVQ to the characteristics of our institution and taking as a reference the previous situation data, evaluated through the level of completion of the list (data from 2013) and those of the observation direct conducted during 2012.

In the observation, the follow-up of the methodology recommended by the WHO was evaluated. For this, five observers were instructed, and a concordance study of attributes was carried out to evaluate their responses (Kappa concordance index). Each of the three moments on the list was differentiated: entry, pause, and exit.

The action plan consists of two lines of work, one directed towards professionals and the other towards patients, organized by the following activities in the 2013-2015 period:

  1. Activities aimed at professionals:
  • Appointment of a physician, a specialist in general surgery, as the person in charge of the project.
  • Dissemination to the surgical services of the incorporation of the hospital to the cooperative action PaSQ-WP5 / Surgical checklist, remembering the responsibility that this safe practice must be assumed by all members of the surgical team.
  • Review and modification of the checklist procedure (prepared in 2009) without changing the number of items, adapting it to our flow of patients and work circuits, and including the specific responsibilities of each member of the surgical team in completing it.
  • Formation of a team of seven professionals as instructors from the list. For the training, the video “Connect with the WHO list” was used, made, and interpreted by professionals from our hospital and available on the muricidal website
  • Evaluation of the level of completion of the list in operated patients.

Carrying out evaluation rounds, the objective of which was to monitor in situ the correct completion of the list and advise on the errors identified. Special emphasis was placed on teamwork and improved communication. The rounds were carried out by instructors trained for this purpose.

  • Evaluation of the perception of the list by professionals, through a survey extracted from the questionnaires of the HAS (Hate Autorité de Santi), provided by the Project of the European Network for Patient Safety and Healthcare Quality.
  • Barrier analysis, which was carried out using the brainstorming technique and nominal group.

Safety training for all members of the surgical team. Ten 20-minute sessions were scheduled, covering reported security incidents related to misidentification, wrong site, sample errors, etc. .; Emphasis was placed on the culture of teamwork and learning from mistakes as the basis of the LVQ, in particular, and of safety in the health field, in general, as well as the seriousness and relevance of the events that can be avoided.

Collaboration in a national project for the use of the list led by the Ministry of Health.

Evaluation of the indicators proposed by the Joint Action Paz: Percentage of operated patients to whom the LVSQ has been applied and postoperative mortality.

  1. Activities seeking the involvement of patients:

The information leaflet Safe Surgery Saves Lives was designed and given to the patient in the consultation prior to the intervention.

This activity seeks a double objective, to inform the user of the usefulness of the list and to promote the active participation of patients in their own care process and in safety in the surgical field, stimulating the participatory spirit of the patient and inducing the healthcare professional to develop healthcare activity in a safe environment.

The variables used in the analysis were:

  1. Direct observation: It was assessed as correct when the time of completion was adequate, and all LVQ items were filled in when asked aloud.
  2. Presence of the list in the clinical history of the operated patients.
  3. Data obtained from the evaluation rounds: The procedure is followed in the round or not, and if it is not followed, if a recommendation is made to improve the methodology of the list.
  4. Completion of the four differentiated sections of the list perception survey.
  5. Barriers detected

The data were analyzed by statistical study for the variables of interest. In the direct observation variable, the 95% confidence intervals of compliance with this item were obtained. For the rest of the variables, except in the case of barriers, the incidence percentage has been calculated by contrasting the growth in the period considered through a non-parametric test of proportions.

All analyzes were performed with the IBM SPSS Statistics 19.0 statistical package (SPSS Inc., Chicago, Illinois, USA).

General Surgery Instruments


  1. Prior to the experience. From the direct observation data, it stands out that the Kappa index was 0.59 (moderate strength of agreement). A total of 96 direct observations were made (from a sampling frame of 135 interventions), obtaining compliance of 55.2% at entry (CI + 8.4), 26.1% (CI + 8.7) at the pause, and 23% (CI + 8.4) at the start, with a reliability of 95%.
  2. Results derived from the activities of the Action Plan:

The data on the presence of the skipjack in the clinical history (Figure 3) reflects an improvement in the level of compliance with respect to the initial measurements. After performing a contrast for the difference in proportions, it is observed that this difference is statistically significant as the p-value associated with the contrast is very small, practically null.

During 2015, 66 evaluation rounds were carried out. The methodology of the list was met in 68.2%, and in 32.8% that was not met, a recommendation was made. In most of the occasions in which the list was not completed correctly, the questions were asked verbally and filled in later.

The survey was delivered to 190 professionals in the surgical area (Figure 4). The response rate was 48% (92 surveys). The professional’s opinion on the usefulness of the list is positive (score equal to or greater than 3) in 73 of the cases (79.8%). In the section on difficulties arising from the use of the list, 58 cases (51.8%) consider that it is difficult to apply in emergency interventions, 55 (59.5%) that it is difficult for a nurse to manage the list, and 47 (51.2%) believe that the exchange of information aloud between the different professionals involved is difficult to obtain. When asked if the list has helped to identify and intercept risk-bearing events (identification errors, surgical site,

From the analysis of barriers, the over-registration, lack of leadership of the list manager, little involvement of the physicians, and absence of teamwork stands out.


The implementation of the LVQ in our center began in 2009, encountering barriers from the beginning. This response coincided with that of other hospitals, as Soria et al. in their study on the difficulties in the implementation of the list in the operating rooms of the Region of Murcia (3). These difficulties have been recognized, in national and international centers, as a limiting factor in the application of the checklist (4), (5). The hospital’s participation in the PaSQ-WP5 / Surgical Checklist project has given us the opportunity to share and exchange information and experiences with other centers. In recent years, surgical activity has increased considerably in Spain, which has led to a change in large part of the healthcare processes. The introduction of new techniques, although less invasive, they continue to cause adverse events. Although simultaneously with technical evolution, practices have been emerging aimed at guaranteeing adequate quality and safety conditions, as is the case with LVQ (6,7), it seems that learning complex techniques are easier than changing attitudes.

In this sense, the use of LVQ implies changes both in the systems and in the behavior of the surgical teams (8); and if your goal is safety optimization, educational interventions and safety awareness among healthcare professionals are required to improve the effective use of LVQ (3, 4). The appreciation that the list is an instrument of administrative control, as an imposed norm, despite the participation in the elaboration of the procedure by numerous surgical professionals, has led to a rejection that we must save based on promoting safe attitudes of the protagonists, professionals, and patients. It is not about imposing the mandatory use of the list but about convincing that its compliance reduces the possibility of avoidable adverse events. What’s What’s more, the efforts required to make it operative vary considerably by the hospital and according to the characteristics of the intervention (3). Our data show that the perception of professionals towards the list is positive, as in the analysis by Rodrigo Rincon et al. (9), which leads us to think that it should be accepted as a safe practice.

In the identification of barriers, and as in other studies, we found that the lack of leadership, the consumption of time in its completion without a perceived benefit, the difficulty in identifying the responsibility of each professional, and the scarce communication and absence of teamwork are the factors that condition our current situation (5). Many of the barriers identified for the successful implementation of the LVQ depend on the organization and cultural factors of each center (5). However, the global perception of the utility of the LVQ in our case was positive for about 80% of the respondents, which reflects a favorable attitude to continue improving its implementation.

In the Haynes study (8), LVQ implantation was associated with a significant reduction in the rates of complications and mortality associated with surgery. However, other studies have not found a significant decrease in morbidity and mortality and suggest that LVQ may be less effective in practice than previously suggested in the literature (10). In our experience, we have not assessed the impact on surgical morbidity and mortality or whether it increases hospital costs or lengthens the time of the intervention, which constitutes a limitation in our study. All efforts have been directed to trying to improve the implementation of this practice, although we plan to do so in the immediate future.

However, the purpose of this initiative, to improve patient safety by trying to reduce avoidable adverse events, justifies the effort made to optimize the implementation of the list. Furthermore, analogously to the results of Fourcade et al. (5), we believe that our findings and those derived from the Paz project have relevant implications for the design, use, and assessment of the LVQ by national health authorities. Likewise, an improvement in the use of the list is possible and should be considered an objective to be achieved by quality management programs in the centers (3).


The Surgical Verification List is an effective tool when it comes to improving the safety of the surgical patient, which can be implemented in the Surgical Areas of any hospital, although it supposes establishing a new dynamic and assumption of roles of the different professionals involved in performing the procedure. Same. The levels of implantation reached in our institution are remarkable, but there is still room to improve its completion. As has been shown, making it mandatory is not enough.

We are convinced that the involvement of professionals in the analysis of the LVQ implementation problems, the adoption of measures for its correct use, the sharing of difficulties and training and teamwork together with the involvement of professionals and patients, as tools to overcome barriers, will result in a decrease in surgical complications and an improvement in the quality of care until reaching what the WHO defined as safe surgery.