- Open Access
Utilization of surgical safety checklists by urological surgeons in Germany: a nationwide prospective survey
© Borgmann et al. 2015
Received: 19 August 2015
Accepted: 2 November 2015
Published: 10 November 2015
We aimed to investigate the contemporary usage rate and habits of the WHO Surgical Safety Checklist (SSC) in German urological departments.
We designed a 26-item questionnaire that was sent to all urological departments in Germany. The primary aim of this study was to evaluate the usage rate of the SSC. Secondary aims were to compare perioperative characteristics of users vs. non-users of the SSC and to assess circumstances of the SSC application.
A total of 213 of 234 (91 %) urological departments were users of the SSC, and 21 (9 %) were non-users. SSC users had more often a standard protocol, took less time and had fewer people involved for checking perioperative patient data compared to non-users. Financial budgeting for the SSC existed in 55 (24 %) departments and for patient safety in 73 (32 %) departments.
The usage rate of the SSC in urological departments in Germany is high despite restricted financial budgeting. Users of the SSC profit by saving time and manpower for checking perioperative patient data.
Surgery is one of the most complex health interventions to be delivered. An estimated 234 million people require surgical treatment every year for different medical reasons , and adverse events in surgery were reported to occur in 14 % of patients . Among all types of surgery, the rate of preventable adverse events was 71 % for transurethral resection of the prostate or bladder, which was the second most common of all operations and thus seems to possess significant potential for improvement . Urology as a surgical discipline implies various dangers for patient safety because it is a high-volume and a high-technology discipline. Instruments used in endourology or in robotic surgery could endanger the success of an operation due to malfunctions of the technical system . An investigation on wrong-site surgery found that of 126 wrong site surgeries reported, 14 (11 %) were urological . The Joint Commission on Accreditation of Healthcare Organizations identified three key components to reduce the risks of wrong-site surgery: preoperative verification, site marking, and a timeout in the operating room, ensured by a safety checklist .
The Safe Surgery Saves Lives Study Group at the World Health Organization published a perioperative surgical safety checklist (SSC) in 2008 . The introduction of the SSC in eight hospitals around the world was associated with a reduction in deaths from 1.5 % to 0.8 % and in major complications from 11.0 % to 7.0 % . In a following study, de Vries et al. reported that implementation of a comprehensive checklist in hospitals with a high standard of care was associated with a reduction in postoperative complication rate from 27.3 % to 16.7 % . Despite the existing evidence for the use of the SSC, little is known about its real usage rate. To date, there are no reports in the medical literature on the usage rate of the SSC for the field of urology. Furthermore, usage habits of the SSC and reasons and circumstances of non-users of the SSC have not been explored.
The objective of this study was to evaluate the usage rate of the SSC in urological departments in Germany. Secondary aims were to compare perioperative characteristics of users vs. non-users of the SSC and to assess circumstances of the SSC application.
Development of the survey
Administration of the survey
Before administration, the survey was tested for usability and technical functionality by doctors from the investigators’ department. It was then sent out to the 332 urological departments via email containing the web link to the online-survey. Once the survey was started an answer to every question was mandatory until completion. The timeframe for data collection via email distribution of the survey was 2 weeks. In order to increase the response rate, the survey was printed out and sent to all 332 urological departments as a paper version. Enclosed was a note not to fill out the paper survey if the online version had already been completed. The timeframe for data collection via postal distribution of the survey was 8 weeks.
Statistical calculations were performed using Statistical Package for the Social Sciences 22.0 software (SPSS Inc., Chicago, IL, USA). The groups of users of the SSC and non-users of the SSC were compared with regard to different parameters. To test whether a standard protocol for checking perioperative patient data was used more frequently by users of the SSC or by non-users of the SSC, the χ2 test was applied. The Mann–Whitney U-test was used to assess differences concerning how many people were engaged in and how much time was consumed for checking perioperative patient data. A p-value of less than 0.05 was considered significant.
Use and practicability of surgical safety checklist
Characteristics of users and non-users of the SSC
Comparison of users and non-users of the surgical safety checklist
Users of the checklist (n = 213)
Non-Users of the checklist (n = 21)
Since when do you use the checklist?
Has the implementation of the checklist been tried?
yes, before 2010
yes, in 2010
yes, in 2011
yes, in 2012
yes, in 2013
Does a standard protocol exist for using the checklist?
Does a standard protocol exist for checking perioperative patient data?
* P = 0.001
Who fills out the checklist?
Who checks perioperative patient data?
People involved per case
People involved per case
* P < 0.001
How long does it take to fill out the checklist?
How long does it take to check perioperative patient data?
Less than 30s
Less than 30s
* P = 0.008
More than 3 min
More than 3 min
How do you consider the use of the checklist?
Why is the checklist not used in your clinic?
Reasonable and not laborious
Reasonable and laborious
Not reasonable and not laborious
Not reasonable and laborious
Are you interested in using the checklist?
I don’t know
Resources for SSC and potential for improvement
A survey on the use of the SSC was sent out to all urological departments in Germany. The results of a representative sample showed a high, but incomplete, usage rate of the SSC of 91 %. The users of the SSC needed less time and fewer people to check perioperative patient data than the non-users. An improvement of the SSC through adaptation to specific procedures in minimally invasive and prosthetic urological surgery was found to be useful by the majority of departments.
The usage rate of the SSC was 91 % in our series of urological departments in Germany. Recent surveys reported a slightly lower usage rate in Switzerland of 79 %  and in Ireland of 78 % . The SSC has been mandated for use in surgical procedures in several countries including Sweden, the United Kingdom, and the USA. In England and Wales it has been modified by the National Patient Safety Agency in order to adjust it to national structures and processes. Examples of different versions of the SSC are shown in Additional file 1. Studies on the 30-day morbidity and mortality between countries with overall and fractional use the SSC might shed light on whether a mandated use of the SSC is beneficial.
Although the usage rate of the SSC found for urological departments in Germany was high this does not automatically go along with compliance to the SSC, which represents an unresolved conundrum in the current age of safety checklists. A recent prospective observational study of 854 surgeries performed in Colorado revealed a uniformly poor compliance with respect to assessment of case duration, blood loss, anesthesiologists’ concerns, or display of essential imaging . Moreover, active participation by physicians was observed in only 71 % of surgeries . Our survey respondees claimed higher percentages for involvement of anesthesiologists (87 %) and surgeons (85 %), however the crucial distinction of use of the SSC and compliance to the SSC has to be kept in mind when interpreting our findings.
The time consumption for checking perioperative patient data was lower for the group of users of the SSC than for non-users. Our results of an average time consumption of less than 2 min for completion of the SSC are in agreement with the time consumption found by Taylor et al. . Moreover, an observational study found that preoperative safety briefings did not delay the operating theatre start time . The perception of the users of the SSC was very positive in our population. 98 % found the SSC to be meaningful, and only 21 % found it to be laborious. Accordingly, Norton et al. reported that 89 % of hospital staff believed that the checklist has improved patient safety in the perioperative environment .
Only 32 % of departments had a financial budget for patient safety, and only 24 % had a budget for the SSC. In this context, the question of cost effectiveness of the SSC must be discussed. Costs of implementing a checklist mostly involve checklist development and modification, formal staff notification, training, and additional operating room time. In 2010, Semel et al. performed a hypothetical decision analysis of the checklist introduction . Per-use cost of the SSC was only $11 and it generated cost savings once it prevented at least five major complications, since the cost of a major surgical complication was found to be $11,626 on average . Furthermore, hospitals may realize savings through gains in efficiency by introduction of the SSC. A checklist use in operating rooms resulted in improved nurse retention and a decrease in the number of operations that were cancelled or delayed . Additional evidence suggests that operative briefings may actually decrease disruptions to the surgical workflow . In summary, evidence supports cost-effectiveness of the SSC and thus financial budget should be provided for this purpose.
Despite the described success of the SSC, there is still much to be improved. Since every specialty has its own specific needs, the adaptation of the SSC to urological conditions was considered useful by 63 % of the departments. An example for adaptation of the SSC was presented by Khan et al. who developed a comprehensive checklist to be used in operating theatres with advanced robotic technology . The SSC was also adapted by interventional radiologists according to their specific needs . In our survey, the subspecialties of prosthetic and minimally invasive urological surgery were regarded to be especially suitable for adaptation of the SSC. A second team timeout after 4 h for robotic surgery was proposed by Song et al. in order to further improve patient safety during long-lasting operations . The complication rate has been shown to increase linearly over time with a steep increase for long operations . However, only 27 % of responders in our survey considered the introduction of a second team time out after 4 h of operating time to be useful.
There are some limitations to the findings of our study due to survey methodology. Although the response rate of 70 % was very high for a survey, the findings might not be representative for all urological departments because 30 % did not respond. We assume that users of the SSC tended to answer the survey more frequently than non-users, and thus the real usage rate of the SSC might be slightly lower than 91 %. Furthermore, there is the potential for a double answer from one department for both the online and the paper version of the survey, which were sent out successively. However, the paper version included a note not to fill out the paper survey if the online version had already been completed. Finally, our survey was limited to the use of the SSC and did not monitor the compliance to the SSC in terms of quality and performance level of adhering to all required steps in the protocol.
We found a high usage rate of the SSC in urological departments in Germany of 91 %, although these departments often lack a budget for the SSC and for patient safety. Users of the SSC found it reasonable and saved time and manpower for checking perioperative patient data compared to non-users. The checklist should be understood not merely as a list of items to be checked off, but as an instrument for the improvement of communication, teamwork, and safety culture in the operating room, and it should be used accordingly.
We thank all participators of the survey for their contribution.
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