Table 2 Categories, subcategories and examples of supporting verbatim

Using the checklist

Picking up problems

• The consent said the patient was having his operation on the left hand. It was an emergency operation late at night, the anaesthetist had taken the patient into theatre without talking to the staff and proceeded to give the patient sedation. Then the nursing staff looked at it all and went “nup”. This patient has got the wrong consent! (Int 10, RN)

• And everything should be about layers. So you know the front door should have a layer. The anaesthetic bay should have a layer. The final time out is here. Where it’s most important that everybody check things before any skin is cut…. (Int 28, Surgeon)

Prompting, providing reminders

• And you’ve got reminders, whether it’s the specimen, or the diathermy pad. You know, just so that you’ve completely followed through. It’s a good starting point, as a handover to the recovery phase. (Int 1, RN)

• I guess effectively it’s almost a tick and flick but occasionally something pops up in the process of ticking and flicking there to remind you about something. (Int 26, Anaesthetist)

Tick-n-flick, going through the motions

• The last bit is not done very well, the signout. That’s a tick tick tick thing. (Int 4, 5 RNs)

• If you are not careful about what you are doing, the patient will get checked in and if all the boxes are ticked and nobody actually talks to the patient and confirms with the patient while they are awake that the surgeon knows what they are doing, it doesn’t prevent anything. (Int 18, surgeon)

Checking and rechecking

• So I always check, are you happy with consent prior to bringing the patient in or giving sedation. I never do anything without one of the nurses. I don’t care if another doctor and the surgeon says consent is there. Have the nurses seen consent? Because I think they are much better at checklists than we are. (Int 8, Anaesthetist)

• ……you’re just basically double-checking everything, three, four, five million times, so it can slow down your day then because you want to make sure that the patient comes first and their safety is imperative in our role…. (Int 24, RN)

Modifying and adapting

• We’ve added in cardiac, for example, to make sure that we got, we say “pacing wires”, so they are not meant to be sent up. (Int 20, RN cardiac)

• I might have pinned the head in the wrong direction, but what worries me is that if I do a time out, and then I pin the head that I might, because it’s very easy to go left, right, disorientation…. So I like them [patients] completely positioned and then we do timeout. (Int 28, Surgeon)

Being inclusive and patient-centred

• I felt as a patient I was included and so, nobody was trying to conceal anything from me. The nurse in both cases was saying, “Ok, see the next question is” and so, you know, they will ask you about, you know, previous history or difficulties……(Int 7, Healthcare Consumer)

• If the patient is awake and is having blocks of local anaesthetic and they say “time-out”, I say to the patient “Just listen. If any information about you or what they are saying in the next two minutes is wrong, say something”. (Int 13, RN)

Working independently of others

Working in silos

• We don’t work very well as a team. We have our two separate teams but we’re not a whole team. We’ve got two pods. An anaesthetic pod and a surgical pod. (Int 4, 5 RNs)

• It’s “I have my job. You have your job” and I’m so like, why can’t we just help each other out? It seriously takes two seconds. You come in to the anaesthetics bay, you ask the patient usually five questions – name, date of birth, check the UR number, what are they having done, you check the consent form, you ask them if they have got any metal and when they last ate. (Int 13, RN)

Being task focussed

• Fasting status is more of an anaesthetic nurse concern, but as a scrub or a scout I don’t… probably, when I’m doing the second and third components of the check, I probably don’t think “oh when did they last eat”. I’m concerned about that if I’m in a different role, but when I’m just a scrub scout in the theatre, I probably don’t…. (Int 1, RN)

• The anaesthetic nurse does the sign in bit by themselves. We usually go in and do our own little bit but it’s not the way that it’s meant to be done but it’s getting done and the sign out is just pointless all together. (Int 4, 5 RNs)

Being discipline-centric

• But it’s the communication between the surgical team and the anaesthetic team is probably something that needs to be improved on. I guess it’s because we’re focused on two completely different aspects of this patient. One is focused solely on the airway and that they stay alive, and the surgical team are just… purely to get them in and out. (Int 4 5 RNs)

• I don’t think they really pay attention to it [anaesthetic checklist items]. They [scrub nurses] pay attention to their own check, despite it being very important and a lot of it in their check as well.” (Int 15, RN anaesthetics)

Leading the process

• I work both publicly and privately and somebody will call out the final check just before knife to skin. That’s what we would call timeout and I think that’s probably where I see my role, certainly as the anaesthetist, is often leading the timeout, certainly actively participating. (Int 8, Anaesthetist)

• What I try to do is get everybody together, I try to get the wardsman and the theatre assistant, because they need to know the positioning of the patient, and if they don’t know ahead of time what the positioning of the patient is, then how can they do it? (Int 9, Anaesthetist)

Working in isolation

• An example, this back bit with the sign-in bit, the scrub scout always comes to the anaesthetic nurse and says you haven’t ticked your bit. It’s like, did you watch the DVD? It doesn’t say that’s the anaesthetic nurse bit. (Int 20, RN cardiac)

• The reality is, the anaesthetic nurse will fill this bit in, and she [sic] will leave blank the prosthesis and the essential imaging, and when the scrub scout … And then we leave those blank, and then the scrub scout does her [sic] little check, and she [sic] ticks those bits. (Int 29, 5 RNs)

Communicating checks with others

Making sure, double checking

• I’ll read the identification on the patient and get one of the nurses to ensure their consent, so they’ll double-check it and will ensure their consent on the site and obviously I will make sure that the surgeon is in the room at the time and I won’t let the nurses do it without ensuring that the surgeon is in the room. (Int 8, Anaesthetist)

• And sometimes, the anaesthetic nurse will just pop the head in, in the theatre and say, “Have you got all the prosthesis?” You say, “Yeah.” Because you’re also opening and getting ready. So they just come in and ask …. And, and I’ll often check the screen to make sure that that patients’ scans are on the screen. (Int 29, RNs x 5)

Verbalising information

• We should just verbalise it more, really. We’ve probably always done it. You know, you always check if your specimens are labelled, the equipment was okay, it’s what you always do but this is just a document that says you’ve done it. I think we just don’t verbalise that we’ve done it because it’s unsaid.…(Int 2 8 RN)

• And then the time out, that’s done with everyone, we also incorporate stuff from the sign in, because we discuss antibiotics at that stage. Because it’s there in there, but we discuss it before the operation. (Int 3, 8 Anaesthetic RNs)

Handing over

• But it all goes back to being handed over at the beginning. It always comes back to what is on it at the beginning when we’re passed on the information. I’ve had twice now, children come from the ward with no parent and no nurse to handover. (Int 3, 8 Anaesthetic RNs)

• It’s usually… the anaesthetist. But we also get a handover from the surgical nurse who comes in and tells us what surgery they’ve [patient] had, perhaps what position they were in. If there were any problems with that, if they’ve had local anaesthetic, if they’ve had drains, dressings. Whether they were bleeding… Anything that might be relevant. (Int 6, 3 PACU RNs)

Asking meaningful questions

• But those who are just used to doing tick and flick and not asking the deep meaningful questions, struggle when the meaningful questions are first asked…… (Int 9, Anaesthetist)

• The best question on that safety checklist is implants or prosthetics. I ask patients “have you got any implants or prosthetics in your body?” They look at you like, “what’s that?” “Anything like metal work, pins, plates, screws, stents?” This is how I word it, “anything in your body you weren’t born with?” I suppose implants; people think breast implants and prosthetics, maybe limbs or something…. But it’s funny, as time goes on you figure out different ways of wording questions. (Int 14, RN)