Guide for Developing AWHSC Patient Safety

Policy and Strategic Plan

Abstract

Patient safety practices result in measurable fiscal impact, save lives and decrease morbidity. So, why
isn’t everyone insisting on such interventions everywhere? The answer is not simple. Patient safety
concepts are not clear to those making decisions, research has not been done in many resource-poor
settings to confirm data collected elsewhere, and many authorities still have the misconception that
introducing patient safety practices is a luxury. Patient safety improvement requires a system change
at all levels. Such a change needs a strong national policy accompanied bb a strategic
implementation plan to ensure the policy’s consistency and sustainability. As a basis for enforcing
effective safety practices, a clear policy that serves as a reference and standard by which to judge the
practices is critical. A national patient safety policy is essential but it must reflect the context and
needs of the individual country. To avoid reinventing the wheel, patient safety policy must reference
internationally approved and tested guidelines and policy recommendations.(World Health
Organization 2014)

Hospital situation analysis tools that may be useful in the assessment and monitoring of patient safety
are included.

Introduction

The World Health Organization (WHO) defines patient safety practices as processes or structures
that reduce the probability of adverse events resulting from exposure to the health care system
across a range of diseases and procedures. Patient safety aims at making health care safe for both
clients and health service staff. Patient safety is a system property and the foremost attribute of
quality of care. As such, it is of organizational, managerial and economic concern, in addition to
being of clinical concern to the health care system. Patient safety is a global and regional public
health issue affecting all types of health care systems whether in developed or developing countries.
The majority of health care errors are considered to be preventable. Patient safety is challenged by
not only the complexity of health care processes but also the culture of denial and blame, the two
characteristics that have dominated the environment of problem solving and learning that the
health care service is. In addition, inconsistencies in the reporting and learning systems prevent
collection and dissemination of information in a meaningful way. The overall cost of adverse events
can be considerable. Loss of confidence within clinical teams and loss of reputation and credibility in
the services and facilities are just two of such ramifications. WHO recognizes the importance of
patient safety. Resolution WHA55.18 of 2002 outlined the responsibilities of WHO in providing
technical support to Member States in developing reporting systems, reducing risk, formulating
evidence-based policies, fostering a culture of safety, and encouraging research on patient safety.
The Fifty-eighth session of the Regional Committee for Africa held in Yaoundé, Cameroon, in
September 2008 adopted document AFR/RC58/8 that updated the knowledge about patient safety,
described issues and challenges and proposed actions for improving patient safety in the WHO
African Region. The proposed actions are clearly underlined in that document, articulated under
twelve patient safety areas (see Box 1). The recommendations to enhance the safety of patients
include complementary actions at policy, managerial and clinical levels. The 12 WHO patient safety
action areas:
BOX-1

More than 70% of the world’s population lacks access to surgical, obstetric, and anesthesia care, and
50% risk financial catastrophe from surgery by adopting World Health Assembly Resolution 68.15 in
2015, adequate access to safe and affordable emergency surgery and anesthesia has been prioritized
for all people worldwide by 2030 as a part of universal health coverage.  Surgery is a complex
intervention, requiring a functioning health system, which in turn requires strategic planning.
However, most national health plans have no significant mention of surgical care.  Development of a
national strategy to improve surgical care by simultaneously strengthening appropriate
infrastructure, a well-trained and well-distributed workforce, efficient service delivery, integrated
information management, quality assurance, and adequate financing and governance in low- and
middle-income countries is an innovative approach to improve surgical care. Driven by the national
government and supporting a wider health strategic plan, a national surgical, obstetric, and
anesthesia plan (NSOAP) identifies the current gaps in health care, prioritizes solutions, and provides
an implementation framework (specific time-bound, annually prioritized, costed activities to reach
each goal), a monitoring and evaluation plan, and projected cost. The NSOAP establishes a unified
vision for strengthening of surgical systems and the coordination of efforts required to achieve this.
(Sonderman, Citron, and Meara 2018)

Global Surgery - the Current Situation

It is approaching three years since the Lancet Commission on Global

Surgery (LCoGS) published Global Surgery: evidence and solutions for
achieving health, welfare and economic development. This is an
opportune point to take stock of the direction and progress in scaling
up essential surgical care in sub-Saharan Africa (SSA), the region with
the greatest need and lowest response capacity. The case for investing
in making safe surgery accessible to underserved communities is
compelling: 5 billion people lack access to safe, affordable surgical and
anaesthetic care, with low- and middle-income countries (LMICs)
worst affected; and 33 million people endure catastrophic expenditure
each year in paying for essential, often life-saving surgery. There is
evidence that essential surgery can be delivered safely, cost-effectively
and is affordable and feasible, even in low resource settings. However,
in much of SSA, elective and emergency general surgery is only
available in the few urban hospitals that are staffed by specialist
surgeons. District level hospitals (DLHs) in Malawi and Zambia and
many other African countries deliver emergency obstetrical
interventions – mainly caesarean sections, and occasional
hysterectomies, as well as limited general surgery – mainly hernia
repairs, but also laparotomies and hydrocoele repairs. In Zambia, such
surgery is often undertaken by non-physician clinicians (NPCs) and
medical officers with limited surgical skills and experience, lacking
support and supervision and working in an uncertain legal and
regulatory environment. Yet for rural populations they are often the
only accessible source of elective and life-saving emergency surgery.

The LCoGS produced a blueprint, outlining the inputs, processes and

systems needed for the provision of safe surgical and anaesthesia care,
including1: trained staff; essential infrastructure and equipment;
reliable supply chains, sterilisation and blood supplies; information
systems and financing mechanisms; and referral and care delivery
protocols to minimise delays for communities and patients in
receiving appropriate care. Because of the limited research evidence,
the Commission relied on expert opinion and modelling of scarce
existing data, framed by a comprehensive health systems analysis. It
proposed three ‘must do,’ ‘bellwether procedures’ that first-level
hospitals should be able to undertake – notably caesarean sections,
laparotomies and management of open fractures; and a longer list of
‘should do’ and ‘can do’ procedures, to be undertaken at first level or
referral hospitals, depending on the context. 
Progress Made - National Surgical Plans
Up to 2015, the target year for reaching the millennium development goals and the year
when the LCoGS published its report only 2% of 4064 health targets in national health
strategic plans from 43 African countries covered surgical conditions or care; and 33% of
national health policies had no surgical targets. The LCoGS proposed five dimensions as a
framework for the development of National Surgery, Obstetric and Anaesthesia Plans:
infrastructure, workforce, service delivery, information management and
financing. The Harvard Program in Global Surgery and Social Change (PGSSC) has played a
key role in the development of the national surgical plan in Zambia in 2015-2016. The plan
was developed through reviews of national level data and semi-structured interviews of
country specialists across the disciplines of surgery, obstetrics, and anaesthesia; and
representatives of relevant government ministries; and national and international partners.
The Harvard Program is also supporting the development of national plans in Ethiopia,
Rwanda, Nigeria, Tanzania, and in Madagascar.

Implementation Priorities and Risks

While country national surgical plan design processes have been

consultative, and rightly so, a lack of contextualised research findings
to inform them has been a weakness and it remains a gap in respect to
plans for evaluating implementation. Without a strong empirical base,
there is a risk that national surgical plans will be unrealistic or remain
aspirational. Surgical plans need a clear implementation strategy that
involves local champions, under the leadership of governments, with
strategic links to global leaders and funding agencies. Implementation
strategies should be based on an understanding of national surgical
systems as complex adaptive systems; and should incorporate a
surgical systems research arm for testing the feasibility of solutions in
large population sites. Some countries, such as South Africa, have the
capacity to bring together all these components, with a contextualised
implementation and research agenda. Others may benefit from global-
local research partnerships where large scale or complex research, as
well as associated resource mobilisation, is required. Lessons from
implementing the Millennium Development Goals (MDGs) and other
global indicator strategies can inform investment choices and
implementation priorities, ensuring that progress is measured and
that governments (and global stakeholders) are held accountable by
citizens.
Given the scarcity of empirical research on the reality and potential
for making surgery available to rural populations through DLHs, the
risk is that the voice of district stakeholders may not be represented in
the consultations that inform national surgical plans. Rural and
district areas are the setting for most unmet population surgical need;
and new research evidence is emerging that makes the case for
investing in district level surgical care. This can reduce the demands
on referral hospitals, allowing specialist surgeons to deliver more
complex surgery; and enable DLHs to deliver the ‘must do’ and
potentially many of the ‘should do’ procedures. In countries where
surgery is undertaken by non-specialists, training and quality
assurance systems are essential. Clear career paths are also needed to
ensure professional progression paths exist for surgically trained
NPCs and medical officers at the district level, reducing the need to
pursue careers in urban areas. In many African countries, specialist
surgeons lack the resources to undertake supervisory visits and have
little direct contact with or experience of DLHs, which may lead them
to underestimate the current scale and potential for district surgery;
and, as a result, to recommend that resources be channeled first to
referral hospitals. The dearth of empirical research on surgical
capacity at DLHs has meant that the debate on how rural populations
can be served and who should deliver essential surgery to them –
specialist surgeons, general medical officers or surgically trained NPCs
– has become politicised.

Research for Change

The LCoGS identified some of the rate limiting steps and called for a
systems research agenda to underpin the development and
implementation of national surgical plans, emphasising the need to
identify and test contextualised responses. Yet, despite a World Health
Assembly resolution in 2015, calling for surgical systems scale-up
globally, there is still limited global policy attention to surgery in early
2018. This gap means there is a window of opportunity to coordinate
research initiatives in support of nationally-led surgical systems
development so as to: (i) inform national surgical plans, (ii) test
innovative solutions; and (iii) provide feedback to inform national
scale-up, based on evaluations of feasibility, quality and safety,
affordability, cost-effectiveness and health impact. Subramanian and
colleagues’ systematic review evaluated conceptual participatory
action research models that involve country stakeholders in learning
by doing, incorporating the critical factors that determine how the
results of pilot projects feed into national programmes. The authors
identified and evaluated six models for scaling-up health services and
concluded that there is no ‘one size fits all’ optimal approach as
strategies need to consider the political, organisational and functional
dimensions of scale-up, supporting national stakeholders and
developing local organisational capacity. Successful models place less
emphasis on initial planning, and more on facilitating implementation
and on “learning by doing, embracing error, and linking knowledge-
building with action as implementation is occurring.”

Drawing on this review, we propose the building of country networks

under the coordination of national ministries of health, supported by
regional and global surgical and systems research stakeholders. The
critical processes, when applied to surgical systems scale-up, should
comprise: (i) leadership from ministries of health and national
surgical specialist bodies, supported by surgical systems researchers;
(ii) identification of workforce, other capacity and resource obstacles;
and enablers to the delivery of essential surgical services through
networks of district and referral hospitals; (iii) collaborations
between ministries, researchers, non-governmental organisations and
specialist surgeons in implementing and evaluating training and
supervision interventions, involving government approved surgical
clinicians at DLHs – be they NPCs or doctors; (iv) feedback loops to
allow continuous adaptation of interventions to local contexts,
informing the development and adjusting the implementation of
national surgical plans; and (v) the use of implementation (mixed
methods) research, combining rigorous quantitative measurements of
cost, surgical outputs and outcomes, with qualitative explanatory
evaluations of the complex interventions and processes needed to
quality assure and scale up surgical services. In addition, as outlined
by the Commission,1 countries need to invest in surgical
infrastructure, purchase and maintain essential equipment, develop
reliable supply chains, and ensure that financial mechanisms enable
citizens to access surgical care regardless of social status.
Case Study of Zambia
Zambia provides an interesting case where two independent processes for scaling up a national
surgical service, both under the guidance of Government, developed between 2011 and 2016. Here
we draw on our experience of developing, implementing and evaluating a national surgical training
and supervision intervention in Malawi and Zambia, as part of the Clinical Officer Surgical Training
project (COST-Africa), 2011-2016. Lessons were used to design a new implementation research
project to scale up safe surgery for district and rural populations (SURG-Africa) in Malawi, Zambia,
and Tanzania, 2017-2020. The European Union (EU) awarded 9 million euros to support these
research projects.

The COST-Africa project, which was originally conceived and funded as research of a national NPC
training intervention, was adapted in Zambia in 2012, as advised by national ministries, to focus on
supervision of existing surgically trained NPCs. Ten NPC graduates were deployed during 2013-2014
as surgical clinicians in nine DLHs across nine different provinces, supervised by four provincial
specialist surgeons. In 2015, representatives of the local implementing partner, the national Surgical
Society of Zambia, were invited to join a national working group that was tasked with drafting
Zambia’s national surgical plan. Thereby, lessons from COST-Africa, specifically a well-documented
supervision model, were incorporated into the national surgical plan in 2016, which was launched in
2017. One of the erstwhile provincial surgeons, who had road-tested the COST-Africa supervision
model, was appointed Deputy National Director for Clinical Services in 2017, tasked with
implementation of the national plan. At a meeting in March 2017 of the Ministry of Health with the
new SURG-Africa project team, again led locally by the Surgical Society of Zambia, it was agreed that
the new SURG-Africa project would conduct an in depth-evaluation of the new supervision model,
comprising remote and in-the-field supervision of surgical services at DLHs.

As Paina and Peters state: “the processes or pathways for introducing and scaling up interventions
can be as important as the content of the intervention itself… (and need to comprise) highly
heterogeneous groups of actors.” In Zambia, there has been a serendipitous confluence of events,
including: (i) responsibility for district hospitals was restored to the Ministry of Health in 2015 after a
gap of three years, during which responsibility lay with the Ministry of Community Development &
Maternal and Child Health; (ii) a collaborative approach by the Harvard Global Program and the
Zambia Ministry of Health, including surgical champions, led to the development of a national
surgical plan; and (iii) implementation of the two large EU-funded surgical systems research projects,
one generating lessons to inform the plan and the second providing an opportunity to evaluate
implementation. While there is debate on the sequencing of investments in national and referral
hospitals vis-à-vis district level investments, the processes of developing national surgical plan as a
blueprint for scale up of surgical services have been collaborative and have avoided some negative
features of global health initiatives that impose disease specific interventions on countries with little
regard to context or sustainability. However, if developed without an adequate evidence-base and if
implemented without in-built feedback loops, implementation failure or unsustainable programmes
are real risks.

In Zambia, where the national surgical plan is due to be implemented, and in Tanzania, where such a
plan is being developed in 2017-2018, SURG-Africa aims to test the components of a scalable
national surgical system in 2017-2020, feeding emerging results to national ministries and their
partners, from early 2018. The COST-Africa and SURG-Africa coordinator at the Royal College of
Surgeons in Ireland and the coordinator of the Harvard Program in Global Surgery have established
links, enabling coordinated support to country plans by ‘northern’ partners. However, little can be
achieved without the engagement of country stakeholders, through national surgical associations
working with and under the leadership of Ministries of Health. Participatory action research focusing
on implementation of national surgical plans can then provide the mechanism for translating
evidence on the feasibility, cost-effectiveness, impact and potential for scale-up of tested strategies
into sustainable national programmes for making safe surgery accessible to district and rural
populations in Africa.(Gajewski, Bijlmakers, and Brugha 2018)

TeamSTEPPS™) is a systematic approach developed by the Department of Defense (DoD) and the
Agency for Healthcare Research and Quality (AHRQ) to integrate teamwork into practice. It is
designed to improve the quality, safety, and the efficiency of health care.

Teamwork and Health Care

Physicians, nurses, pharmacists, technicians, and other health care professionals must
coordinate their activities to make patient care safe and efficient. Health care workers
perform interdependent tasks while functioning in specific roles and sharing the common
goals of quality and safety in care. However, even though the delivery of care requires
teamwork, members of these teams are rarely trained together; they often come from separate
disciplines and diverse educational programs.
Given the interdisciplinary nature of the work and the necessity for cooperation amongst
those who perform it, teamwork is critical to ensure patient safety. Teams make fewer
mistakes than individuals, especially when each team member knows his or her
responsibilities, as well as the responsibilities of other team members.7, 8, 9 However, simply
conducting training or installing a team structure does not ensure the team will operate
effectively. Teamwork is not solely a consequence of co-locating individuals together.
Rather, it depends on a willingness to cooperate, coordinate, and communicate while
remaining focused on a shared goal of achieving optimal outcomes for all patients.
Teamwork does not require that team members work together on a permanent basis, yet it is
sustained by a commitment to a shared set of team knowledge, skills, and attitudes (KSAs),
rather than permanent assignments that carry over from day to day.

Team Knowledge, Skill, and Attitude Competencies

The importance of teamwork in health care emerged in anesthesiology over a decade ago
with the work of David Gaba and colleagues who developed Anesthesia Crisis Resource
Management (ACRM).  ACRM was designed to help anesthesiologists effectively manage
crises by working in multidisciplinary teams that include physicians, nurses, technicians, and
other medical professionals. ACRM provides training in specific technical skills and in
generic teamwork skills using patient simulators. The team skills were adopted from research
on aviation teams and include developing a thorough case orientation, making inquiries and
assertions, communicating, giving and receiving feedback, exerting leadership, maintaining a
positive group climate, anticipating and planning, managing workload distribution,
maintaining vigilance, and re-evaluating actions.
In the late 1990s, Dynamics Research Corporation (DRC) conducted a DoD-sponsored
randomized controlled trial to study team training in emergency departments as an error-
reduction strategy. More recently, research on teamwork in health care and its requirements
has spread to other disciplines. For example, Healey, Undre, and Vincet developed
Observational Teamwork Assessment for Surgery (OTAS), a behavioral rating scale that can
be used to assess cooperation, leadership, coordination, awareness, and communication in
surgical teams. Thomas, Sexton, and Helmreich have developed 10 behavioral markers for
teamwork in neonatal resuscitation teams, and Flin and Maran have identified nontechnical
skill requirements for teams in acute medicine.
In 2005, Baker and colleagues reviewed the above literature and other relevant information in
an attempt to define important elements of teamwork in the professional education of
physicians. Baker argues that the KSAs advocated by Salas and colleagues were directly
relevant to health care. These competencies must be possessed by individual health care
providers to perform on a variety of teams with which they interact on a daily basis, as well
as the numerous tasks that require coordination by health care workers. As discussed below,
these competencies served as the foundation for the Team STEPPS Initiative. Table
1 presents each KSA, its definition, behavioural examples, and the supporting evidence
references.(King et al. 2008)

Nontechnical skills must be highlighted in surgical training in low- and middle-income countries. The
NOTSS-VRC curriculum can be implemented without additional technology or significant financial
cost. Its deliberate design for resource-constrained settings allows it to be used both as an
educational course and a quality improvement strategy. Our research demonstrates it is feasible to
improve knowledge and attitudes about NOTSS through a 1-day course, and represents a novel
approach to improving global surgical safety.(Lin et al. 2018)

A checklist is ‘a formal list used to identify, schedule, compare or verify a group of elements or
used as a visual or oral aid that enables the user to overcome the limitations of short-term
human memory’ . The use of checklists in health care is increasingly common. One of the first
widely publicized checklists was for the insertion of central venous catheters. This checklist, in
addition to other team-building exercises, helped significantly decrease the central line infection
rate per 1000 catheter days from 2.7 at baseline to zero. Building on this early success, the
World Health Organization's Patient Safety Programme ‘Safe Surgery Saves Lives’ developed a
Surgical Safety Checklist as a means of improving the safety of surgical care around the world. In
a multinational study involving eight hospitals from diverse economic settings, its use improved
compliance with standards of care by 65% and reduced the death rate following surgery by
nearly 50%.(Weiser et al. 2010)

Surgical checklist development process can be broken down into five steps: content and format,
timing, trial and feedback, formal testing and evaluation, and local modification. We believe that
these five steps adapted from the aviation industry and applied to the development of the WHO
Surgical Safety Checklist can help inform the development of future medical checklists.(Fudickar
et al. 2012)
Figure-1 showing how to develop surgical check list
Safe Surgery for All: Early Lessons from Implementing a National Government-
Driven Surgical Plan in Ethiopia:
Recognizing the unmet need for surgical care in Ethiopia, the Federal Ministry of Health (FMOH) has
pioneered innovative methodologies for surgical system development with Saving Lives through Safe
Surgery (SaLTS). SaLTS is a national flagship initiative designed to improve access to safe, essential
and emergency surgical and anaesthesia care across all levels of the healthcare system. Sustained
commitment from the FMOH and their recruitment of implementing partners has led to notable
accomplishments across the breadth of the surgical system, including but not limited to:
(1) Leadership, management and governance—a nationally scaled surgical leadership and
mentorship programme, (2) Infrastructure—operating room construction and oxygen delivery plan,
(3) Supplies and logistics—a national essential surgical procedure and equipment list, (4) Human
resource development—a Surgical Workforce Expansion Plan and Anaesthesia National Roadmap,
(5) Advocacy and partnership—strong FMOH partnership with international organizations, including
GE Foundation’s SafeSurgery2020 initiative, (6) Innovation—facility-driven identification of problems
and solutions, (7) Quality of surgical and anaesthesia care service delivery—a national peri-operative
guideline and WHO Surgical Safety Checklist implementation, and (8) Monitoring and evaluation—a
comprehensive plan for short-term and long-term assessment of surgical quality and capacity. As
Ethiopia progresses with its commitment to prioritize surgery within its Health Sector
Transformation Plan, disseminating the process and outcomes of the SaLTS initiative will inform
other countries on successful national implementation strategies. The following article describes the
process by which the Ethiopian FMOH established surgical system reform and the preliminary results
of implementation across these eight pillars.(Burssa et al. 2017)

Service delivery was low across hospitals with a mean(s.d.) of 5(6) surgical cases per week and a
narrow range of procedures performed. Hospitals reported varying availability of basic
infrastructure, including constant availability of electricity (9 of 15) and running water (5 of 15).
Unavailable or broken diagnostic equipment was also common. The majority of surgical and
anaesthesia services were provided by non-physician clinicians, with little continuing education
available. All hospitals tracked patient-level data regularly and eight of 15 hospitals reported
surgical volume data during the assessment, but research activities were limited. Hospital
financing specified for surgery was rare and the majority of patients must pay out of pocket for
care.
Conclusion
Results from this study will inform programmes to simultaneously improve each of the health
system domains in Ethiopia; this is required if better access to and quality of surgery, anaesthesia
and obstetric services are to be achieved.(Iverson et al. 2019)
Development of a surgical assessment tool for national policy monitoring &
evaluation in Ethiopia: A quality improvement study
One key challenge in improving surgical care in resource-limited settings is
the lack of high-quality and informative data. In Ethiopia, the Safe Surgery
2020 (SS2020) project developed surgical key performance indicators (KPIs)
to evaluate surgical care within the country. New data collection methods were
developed and piloted in 10 SS2020 intervention hospitals in the Amhara and
Tigray regions of Ethiopia.(Bari et al. 2021)

In Ethiopia there is wide variation in accessibility, with hospital-to-

population ratios ranging from 1:99,010 to 1:1,082,761. The overall
physician to population ratio ranges from 1:4715 to 1:107,602. The average
hospital has one to two operating rooms, 4.2 surgeons, one gynecologist,
and 4.5 anesthesia providers—although in all but three hospitals
anesthesiology was provided by nonphysician personnel only (i.e., a nurse
anesthetist). Access to continuous electricity, running water, essential
medications, and monitoring systems is very limited in all hospitals
surveyed, although such access did vary across regions.

Survey of Ethiopia’s hospital resources attempts to identify specific areas of

need where resources, education, and development can be targeted.
Because the major surgical mortality comes from late presentations,
increasing accessibility through infrastructure development would likely
provide a major improvement in surgical morbidity and mortality rates.
Infrastructure limitations of electricity, water, oxygen, and blood banking
do not prove to be significant barriers to surgical care. The increasing
number of physicians is promising, although efforts should be directed
specifically toward increasing the number of anesthesiologists and surgeons
in the country.(Chao et al. 2012)

Facilities had on average 62% of SARA items necessary for both basic surgery and comprehensive
surgery. Primary, general, and specialized facilities offered on average 84%, 100%, and 100% of SARA
basic surgeries, and 58%, 73% and 90% of SARA comprehensive surgeries, respectively. An average
of 68% of SaLTS primary surgeries were available at primary facilities, 83% at general facilities, and
100% at specialized facilities. General and specialized hospitals offered an average of 80% of SaLTS
general surgeries, while one specialized hospital offered 38% of SaLTS specialized surgeries .

Conclusion

While the modified SaLTS Tool provided evaluation against Ethiopian national benchmarks, the
resultant assessment was much lengthier than standard international tools. Analysis of results using
the SARA framework allowed for comparison to global standards and provided insight into essential
parts of the tool. An assessment tool for national surgical policy should maintain internationally
comparable metrics and incorporation into existing surveys when possible, while including country-
specific targets.(Drum et al. 2018)
Existing evidence suggests that communication failures are common in the
operating room, and that they lead to increased complications, including
infections. Use of a surgical safety checklist may prevent communication
failures and reduce complications. Initial data from the World Health
Organization Surgical Safety Checklist (WHO SSC) demonstrated
significant reductions in both morbidity and mortality with checklist
implementation. A growing body of literature points out that while the
physical act of “checking the box” may not necessarily prevent all adverse
events, the checklist is a scaffold on which attitudes toward teamwork and
communication can be encouraged and improved. Recent evidence
reinforces the fact the compliance with the checklist is critical for the effects
on patient safety to be realized.(Pugel et al. 2015)

Conclusion
The modern surgical environment is complex, and communication errors
are relatively common. As described, use of the SSC has become common
throughout the world. While checklists show promise in the reduction of
surgical morbidity and mortality, there is also evidence that these
improvements are not realized without careful attention to implementation
strategy. When deciding to implement checklists in the OR, administrators
should assess the climate of their hospital in order to make the checklist
relevant to those who will be using it rather than an additional hurdle to
jump over. Providing feedback to teams regarding patient outcomes and
OR performance may be a valuable strategy to promote buy-in at the
provider level [33]. In addition, encouraging customization of the checklist
to fit the needs of the team may promote a feeling of ownership over the
checklist, increasing compliance along the way [33], [36]. Without the
support of staff members, it is unlikely that the checklist will lead to any
changes in patient outcomes. For now, the surgical community should view
the checklist as a tool for improving communication and safety culture, and
be realistic about its direct impact on patient safety.

Results from the initial prospective, sequential, time-series observational

study showed significant reductions in complications, in-hospital mortality,
rates of unplanned reoperation, and surgical site infection (SSI) compared
to pre-checklist rates.(Pugel et al. 2015)
References

Allegranzi, Benedetta, Bassim Zayed, Peter Bischoff, N. Zeynep Kubilay, Stijn de Jonge,
Fleur de Vries, Stacey M. Gomes, Sarah Gans, Elon D. Wallert, Xiuwen Wu,
Mohamed Abbas, Marja A. Boermeester, E. Patchen Dellinger, Matthias Egger, Petra
Gastmeier, Xavier Guirao, Jianan Ren, Didier Pittet, and Joseph S. Solomkin. 2016.
‘New WHO Recommendations on Intraoperative and Postoperative Measures for
Surgical Site Infection Prevention: An Evidence-Based Global Perspective’. The
Lancet Infectious Diseases 16(12):e288–303. doi: 10.1016/S1473-3099(16)30402-9.

Allegranzi, Benedetta, Bassim Zayed, Peter Bischoff, N. Zeynep Kubilay, Stijn de Jonge,
 Fleur de Vries, Stacey M. Gomes, Sarah Gans, Elon D. Wallert, Xiuwen Wu,
Mohamed Abbas, Marja A. Boermeester, E. Patchen Dellinger, Matthias Egger, Petra
Gastmeier, Xavier Guirao, Jianan Ren, Didier Pittet, and Joseph S. Solomkin. 2016.
‘New WHO Recommendations on Intraoperative and Postoperative Measures for
Surgical Site Infection Prevention: An Evidence-Based Global Perspective’. The
Lancet Infectious Diseases 16(12):e288–303. doi: 10.1016/S1473-3099(16)30402-9.

Alp, Emine, Dilek Altun, Aysegul Ulu-Kilic, and Ferhan Elmali. 2014. ‘What Really Affects
Surgical Site Infection Rates in General Surgery in a Developing Country?’ Journal
of Infection and Public Health 7(5):445–49. doi: 10.1016/j.jiph.2013.11.006.

Badia, J. M., A. L. Casey, N. Petrosillo, P. M. Hudson, S. A. Mitchell, and C. Crosby. 2017.

‘Impact of Surgical Site Infection on Healthcare Costs and Patient Outcomes: A
Systematic Review in Six European Countries’. Journal of Hospital Infection
96(1):1–15. doi: 10.1016/j.jhin.2017.03.004.

Broex, E. C. J., A. D. I. van Asselt, C. A. Bruggeman, and F. H. van Tiel. 2009. ‘Surgical
Site Infections: How High Are the Costs?’ Journal of Hospital Infection 72(3):193–
201. doi: 10.1016/j.jhin.2009.03.020.

Legesse Laloto, Tamrat, Desta Hiko Gemeda, and Sadikalmahdi Hussen Abdella. 2017.
‘Incidence and Predictors of Surgical Site Infection in Ethiopia: Prospective Cohort’.
BMC Infectious Diseases 17(1):119. doi: 10.1186/s12879-016-2167-x.

Bari, Sehrish, Joseph Incorvia, Katherine R. Iverson, Abebe Bekele, Kaya Garringer, Olivia Ahearn,
Laura Drown, Amanu Aragaw Emiru, Daniel Burssa, and Samson Workineh. 2021. ‘Surgical
Data Strengthening in Ethiopia: Results of a Kirkpatrick Framework Evaluation of a Data
Quality Intervention’. Global Health Action 14(1):1855808.

Burssa, Daniel, Atlibachew Teshome, Katherine Iverson, Olivia Ahearn, Tigistu Ashengo, David
Barash, Erin Barringer, Isabelle Citron, Kaya Garringer, and Victoria McKitrick. 2017. ‘Safe
Surgery for All: Early Lessons from Implementing a National Government-Driven Surgical
Plan in Ethiopia’. World Journal of Surgery 41(12):3038–45.

Chao, Tiffany E., MacKenzie Burdic, Karan Ganjawalla, Miliard Derbew, Christopher Keshian, John
Meara, and Kelly McQueen. 2012. ‘Survey of Surgery and Anesthesia Infrastructure in
Ethiopia’. World Journal of Surgery 36(11):2545–53.

Drum, Elizabeth T., Rediet Shimeles Workneh, Rahel Tilahun, and KA McQueen. 2018. ‘Safe Surgery
for All: Early Lessons from Implementing a National Government-Driven Surgical Plan in
Ethiopia’. World Journal of Surgery 42(11):3812–13.

Fudickar, Axel, Kim Hörle, Jörg Wiltfang, and Berthold Bein. 2012. ‘The Effect of the WHO Surgical
Safety Checklist on Complication Rate and Communication’. Deutsches Ärzteblatt
International 109(42):695.

Gajewski, Jakub, Leon Bijlmakers, and Ruairí Brugha. 2018. ‘Global Surgery–Informing National
Strategies for Scaling up Surgery in Sub-Saharan Africa’. International Journal of Health
Policy and Management 7(6):481.
Iverson, K. R., K. Garringer, O. Ahearn, S. Alidina, I. Citron, S. Esseye, A. Teshome, S. Mukhopadhyay,
D. Burssa, and Safe Surgery 2020 Collaborators. 2019. ‘Mixed-Methods Assessment of
Surgical Capacity in Two Regions in Ethiopia’. British Journal of Surgery 106(2):e81–90. doi:
10.1002/bjs.11032.

King, Heidi B., James Battles, David P. Baker, Alexander Alonso, Eduardo Salas, John Webster, Lauren
Toomey, and Mary Salisbury. 2008. ‘TeamSTEPPS TM: Team Strategies and Tools to Enhance
Performance and Patient Safety’. Advances in Patient Safety: New Directions and Alternative
Approaches (Vol. 3: Performance and Tools).

Lin, Yihan, John W. Scott, Sojung Yi, Kathryn K. Taylor, Georges Ntakiyiruta, Faustin Ntirenganya,
Paulin Banguti, Steven Yule, and Robert Riviello. 2018. ‘Improving Surgical Safety and
Nontechnical Skills in Variable-Resource Contexts: A Novel Educational Curriculum’. Journal
of Surgical Education 75(4):1014–21. doi: 10.1016/j.jsurg.2017.09.014.

Pugel, Anne E., Vlad V. Simianu, David R. Flum, and E. Patchen Dellinger. 2015. ‘Use of the Surgical
Safety Checklist to Improve Communication and Reduce Complications’. Journal of Infection
and Public Health 8(3):219–25. doi: 10.1016/j.jiph.2015.01.001.

Sonderman, Kristin A., Isabelle Citron, and John G. Meara. 2018. ‘National Surgical, Obstetric, and
Anesthesia Planning in the Context of Global Surgery: The Way Forward’. JAMA Surgery
153(10):959–60.

Weiser, Thomas G., Alex B. Haynes, Angela Lashoher, Gerald Dziekan, Daniel J. Boorman, William R.
Berry, and Atul A. Gawande. 2010. ‘Perspectives in Quality: Designing the WHO Surgical
Safety Checklist’. International Journal for Quality in Health Care 22(5):365–70. doi:
10.1093/intqhc/mzq039.

World Health Organization. 2014. ‘Guide for Developing National Patient Safety Policy and Strategic
Plan’.