Understanding WHO surgical checklist implementation: tricks and pitfalls. An observational study.

Background: The purpose of the present study was to assess the reliability of implementation data regarding the surgical safety checklist (SSC) and to identify which factors influence actual implementation.

Methods: The study was a retrospective record-based evaluation in a regional network of nine Spanish hospitals, combined with a complementary direct-observation study that included a survey of the surgical teams' attitudes. SSC compliance and associated factors were assessed and compared in a retrospective sample of 280 operations and a concurrent sample of another 85 surgical interventions.

Results: In the retrospective evaluation the SSC was present in 83.1 % of cases, fully completed in 28.4 %, with 69.3 % of all possible items checked. The concurrent direct-observation study showed that recorded compliance was unreliable (κ < 0.13 for all items) and significantly higher (p < 0.001) than actual compliance. Over-registration occurred across hospitals and surgical specialties. Factors associated with recorded compliance included hospital size, surgical specialty, and the use of an electronic format. In actual (direct-observation) compliance, a positive attitude on the part of the surgeon is an overriding significant factor (OR 12.8), along with using the electronic format, which is consistently and positively associated with recorded compliance but negatively related to actual compliance.

Conclusions: Recorded SSC compliance may be widely unreliable and higher than actual compliance, particularly when recording is facilitated by using an electronic format. A positive attitude on the part of the surgical team, particularly surgeons, is associated with actual compliance. Effective use of the SSC is a far more complex adaptive process than the usual mandatory strategy.