IHP 315 Module 7 Project Two Example

Project Two: Making the Surgical Safety Checklist Real at a Community Hospital

[Student Name]

Southern New Hampshire University

IHP 315: Patient Safety Systems and Strategies

Project Two

[Instructor Name]

[Date]

Project Two: Making the Surgical Safety Checklist Real at a Community Hospital

Maple Grove's four operating rooms perform about 5,000 procedures a year. Last year, an anesthesiologist began a nerve block on the wrong leg before a nurse noticed the site marking, and twice the final sponge count was wrong until a missing sponge was found. Each event happened despite a checklist on the wall. Observation showed why: the checklist was often filled out at the end of the case or read aloud while people were busy with other tasks. This project proposes a plan to make the surgical safety checklist a real conversation that stops errors, drawing on research about what checklists achieve and what makes them work.

The Problem in Detail

Over two weeks, a perioperative nurse educator observed 40 cases using a simple audit tool. The sign-in before anesthesia was done in 34 cases, but the full team was present for only 20. The time-out before incision was performed in all 40, yet in 15 the surgeon was scrubbing or talking during it, and in 9 no one confirmed the laterality aloud. The sign-out, which covers counts, specimen labels and concerns for recovery, was completed during the case in only 18 and often recorded afterward. Staff interviews revealed a belief that the checklist was a regulatory requirement rather than a safety tool and discomfort among nurses about asking surgeons to stop.

What the Evidence Shows

Haynes et al. (2009) brought the World Health Organization's 19-item Surgical Safety Checklist into eight hospitals on several continents, some well resourced and some very poor. After introduction, the rate of death fell from 1.5% to 0.8%, and inpatient complications fell from 11.0% to 7.0%. The study compared periods before and after rather than randomized groups, yet gains of that size across such different hospitals drew attention everywhere.

Urbach et al. (2014) examined what happened when Ontario required all hospitals to use a surgical checklist. Comparing large numbers of procedures before and after the mandate, they found no significant reductions in deaths or complications. Commentators and the authors suggested that checklists may help only when teams use them genuinely, with training and commitment, and that a mandate can produce compliance on paper without changing behavior. Read side by side, these studies imply that the checklist works less like a drug and more like a cue for teamwork, and its effect depends on implementation.

Lessons from a Program That Worked

Pronovost et al. (2006) described a statewide effort across Michigan's intensive care units built around a short checklist to prevent catheter-related bloodstream infections. Infection rates fell sharply and stayed low for the eighteen months studied. The program combined the checklist with a structured effort to improve safety culture, clear roles for physician and nurse leaders on each unit, regular feedback of data and clear permission for a nurse to halt line insertion whenever a step was skipped. Those supporting elements, not the checklist alone, are what the Maple Grove plan borrows.

Culture as Part of the Plan

Weaver et al. (2013) reviewed interventions intended to strengthen safety culture and found that team training, executive walk rounds and unit-based safety programs can improve staff perceptions of culture, although evidence linking them to patient outcomes was limited. For the operating rooms, team training focused on speaking up is especially relevant, because nurses reported discomfort about asking surgeons to pause. Culture work is therefore built into the plan rather than treated as an optional extra.

The Improvement Plan

The plan has six elements. First, the chief of surgery and the director of perioperative services jointly announce that the checklist is a safety tool, that anyone may stop a case until it is complete and that no one will be penalized for doing so. Second, a small team of a surgeon, an anesthesiologist, a nurse and a surgical technologist adapts the WHO checklist to local practice, removing redundant items and adding laterality confirmation by the whole team. Third, every surgical team member completes a two-hour simulation-based session on running the checklist and speaking up. Fourth, the circulating nurse leads each checklist phase, reading items aloud while all activity stops. Fifth, a perioperative educator observes ten cases a week and gives immediate, friendly feedback. Sixth, results are shared monthly at the surgical department meeting.

Table 1. Plan Elements, Owners and Timeline

Note. Owners were chosen for their authority over each element.

Measures

Process measures come from the weekly observations: the percentage of cases in which all three phases are completed in real time with all team members present and attentive, and the percentage in which laterality is confirmed aloud. Outcome measures include wrong-site events, retained items and surgical site infections, tracked from existing reports and surveillance, recognizing that these events are rare and will take time to show change. A short teamwork climate survey at baseline and twelve months measures culture. A balancing measure, operating room turnover time, checks that the checklist does not cause unacceptable delays.

Risks and Responses

The main risk is the Ontario pattern: compliance on paper without real change. Weekly direct observation, rather than reliance on signed forms, is the plan's main defense. A second risk is surgeon resistance; involving a respected surgeon in design and having the chief of surgery lead the announcement address it. A third is fading attention after the first months, which monthly feedback and quarterly refresher huddles aim to prevent.

If observation shows little improvement by month six, the design team will meet with the teams involved to find out why before adding new elements.

Conclusion

Maple Grove already had a checklist; what it lacked was a checklist that teams used as intended. The evidence shows that checklists work when leaders, training, clear roles, observation and feedback support them. This plan supplies those elements and measures whether the checklist has become a real conversation in every case.

References

Haynes, A. B., Weiser, T. G., Berry, W. R., Lipsitz, S. R., Breizat, A.-H. S., Dellinger, E. P., Herbosa, T., Joseph, S., Kibatala, P. L., Lapitan, M. C. M., Merry, A. F., Moorthy, K., Reznick, R. K., Taylor, B., & Gawande, A. A. (2009). A surgical safety checklist to reduce morbidity and mortality in a global population. New England Journal of Medicine, 360(5), 491-499. https://doi.org/10.1056/NEJMsa0810119

Pronovost, P., Needham, D., Berenholtz, S., Sinopoli, D., Chu, H., Cosgrove, S., Sexton, B., Hyzy, R., Welsh, R., Roth, G., Bander, J., Kepros, J., & Goeschel, C. (2006). An intervention to decrease catheter-related bloodstream infections in the ICU. New England Journal of Medicine, 355(26), 2725-2732. https://doi.org/10.1056/NEJMoa061115

Urbach, D. R., Govindarajan, A., Saskin, R., Wilton, A. S., & Baxter, N. N. (2014). Introduction of surgical safety checklists in Ontario, Canada. New England Journal of Medicine, 370(11), 1029-1038. https://doi.org/10.1056/NEJMsa1308261

Weaver, S. J., Lubomksi, L. H., Wilson, R. F., Pfoh, E. R., Martinez, K. A., & Dy, S. M. (2013). Promoting a culture of safety as a patient safety strategy: A systematic review. Annals of Internal Medicine, 158(5 Pt 2), 369-374. https://doi.org/10.7326/0003-4819-158-5-201303051-00002