Safe surgery: validation of pre and postoperative checklists

ABSTRACT Objective: to develop, evaluate and validate a surgical safety checklist for patients in the pre and postoperative periods in surgical hospitalization units. Method: methodological research carried out in a large public teaching hospital in the South of Brazil, with application of the principles of the Safe Surgery Saves Lives Programme of the World Health Organization. The checklist was applied to 16 nurses of 8 surgical units and submitted for validation by a group of eight experts using the Delphi method online. Results: the instrument was validated and it was achieved a mean score ≥1, level of agreement ≥75% and Cronbach’s alpha >0.90. The final version included 97 safety indicators organized into six categories: identification, preoperative, immediate postoperative, immediate postoperative, other surgical complications, and hospital discharge. Conclusion: the Surgical Safety Checklist in the Pre and Postoperative periods is another strategy to promote patient safety, as it allows the monitoring of predictive signs and symptoms of surgical complications and the early detection of adverse events.


Introduction
Nurses' decision-making processes encompass knowledge in the area of care and management, with an emphasis on patient care. However, for their success, they must occur in line with planning and evaluation, based on an appropriate information system. The information within a health service not only favors decision making, but also the structuring of innovative strategies that significantly help in the management. This is the challenge, from a wider perspective, for the insertion and performance of nurses in the organizational structure of health systems (1) .
Among the management actions is the decision making of the nurses, it is possible to highlight those actions related to patient safety aiming at the prediction and reduction of complications, as well as the early detection of aggravations and adverse events in the postoperative period (2) . In this context, the development of tools that provide information, such as checklists, may promote the early identification of the most frequent problems in the planning of nursing care during hospital stay, discharge plan development and guidance on home care (3) .
The initial milestone, which demonstrated the benefits of using a checklist for the safety of surgical patients, was a study conducted by experts of the World Health Organization (WHO) in eight countries (Canada, India, Jordan, Philippines, New Zealand, Tanzania, England and USA). In total 7,688 patients were investigated, of which 3,733 were investigated prior to the use of the checklist and 3,955 after filling out the checklist, which showed a 36% reduction in surgical complications, 47% in mortality, 50% in infection rates and 25% in the need for a new surgical intervention. It was concluded that the use of the checklist practically doubled the possibility of using safe care standards during surgical treatment of the patients (4) .
These results on the use of the Surgical Safety Checklist (SSC) were highlighted in the WHO Second Global Patient Security Challenge. In Brazil, the Ministry of Health has implemented the Safe Surgeries Programme and recommends the use of SSC before anesthetic induction, before the surgical incision and at the end of the surgery, before the patient leaves the operating room (5) .  (6) .
Other studies show that the use of checklists is a practice encouraged by reducing memory and intuition dependence (7) and reducing errors (8) , thus becoming synonymous with best practice in high-risk areas (9) .
These verification tools can revolutionize the way knowledge is put into practice, as well as being a basic and cost-effective resource for health services (10) .
Considering that the WHO SSC model is applicable in surgical centers, that is, in perioperative moments (before, during and after surgery), it is justified the need for a specific checklist in the pre and postoperative periods in the hospital surgical units. This allows identifying the appropriate preparation of the patients before their referral to the surgical center, as well as the predictive signs of postoperative complications.
Another study concluded that the prevention of problems related to the safety of surgical patient should also be focused on the pre and postoperative periods, as it is estimated that 19% of incidents are associated with the organization of services and care (11) .

The WHO recommends the development of new
checklists for other in-hospital services, as a way of stimulating the safety culture (5) . Thus, based on the international recommendations for safe surgeries, it is the ethical responsibility of the nursing professional to fill the gap identified in relation to the verification of safety elements before the referral of the patient to the surgical center, as well as the identification of predictive factores for postoperative complications.
The objective of this study was to develop, evaluate and validate a surgical safety checklist for patients in the pre and postoperative periods in surgical hospitalization units.

Methods
Methodological study, with a quantitative approach,

(4) A (Act) -Action Phase
This phase refers to the submission of version 3 of the checklist to the validation process by the Committee of Experts, using the Delphi method, through an online panel to reach a consensus. It was established a minimum concordance of 70% for the results of the Average Ranking (AR) in the assessment (13) . This value was calculated by the sum of the frequencies of the responses, multiplied by the score assigned to each Likert scale response (weighting factor) and divided by the sum of the frequencies of each response using the weighted average of the frequencies.      Table 1 shows the assessment of the characteristics and purposes of the SSCPP, with level of agreement >75% and average ranking ≥1. Table 2 shows the data of the assessment on the use of the SSCPP. The questions "Are there any items that need to be more detailed?"; "Is there any topic that should be included for completeness?" and "Is there any topic that should be excluded?" did not reach a minimum level of agreement of 70% and average ranking ≥1, in the first round of assessment by using the Delphi method.
After the first round of the Delphi method, at the suggestion of the experts, the expression "demarcated surgical site" was included in category II (prior to referral of the patient to the surgical center). In category III (return of the patient from the surgical center to the hospitalization unit), the experts requested space to describe the type and location of the drainage and inclusion of the word "others", with space to write in the item related to permeable venous access. In category V (complications), the title was "Other postoperative complications", and the types of shock were added -"septic", "hypovolemic", "cardiogenic", "neurogenic" and "other" -with space to write. As for the exclusion, there were only changes in category V. The item PTE (Pulmonary Thromboembolism) was removed because the term VTE (Venous Thromboembolism) was already in the checklist; the item "Fall" was excluded because it was an incident and not a complication; and the item "dehiscence" was      improve the patterns for the assessment aiming at their use, in a systematic and rigorous way (12) .
It can be understood, then, that the use of PDCA or lack of blood products and death (14) . In this context, the early identification of complications related to operative wound also contributes to guiding the care plan. Therefore, care planning and early identification of transoperative events support the development of the outcome indicators and monitoring of the quality of care and patient safety (5) .  (15) .
The results of the mentioned studies reveal that the use of checklists may contribute to reduce harms to patients. In addition to guiding the evaluation in the perioperative period, the information stored in these lists can also serve to feed databases, and provide support for health institutions and professionals (16) .
However, a validated instrument, as shown here, can provide more reliability for patient safety, reducing the costs of the health system and, in this scenario, the nurse is the professional who collaborates for this reality. In all areas of knowledge, including nursing, the development of validated assessment instruments is a complex process. However, it allows to recognize avoidable risk situations, to plan awareness actions, as well as to favor professional development. In addition, they call for reliability and consistency, as they reflect the quality of the measurement (17) .
The results of this study confirm the reliability of SSCPP and its contribution to the practice of surgical nursing. The confirmation of its reliability shows that the instrument serves to assess the quality of care, effectively manage care aiming at the identification of avoidable risks, and allows corrective actions and readjustment in the objectives through administrative and educational strategies (17) . It is important to highlight that the impacts of checklists are likely to be effective, depending on the implementation process of each hospital (19) . There might be several obstacles for achieving success in the implementation of a surgical checklist, such as organizational and cultural factors within each hospital.
One strategy for achieving success is the continuous feedback from professionals of the service to the hospital administration in order to identify the factors that prevent the effective implementation of checklists for safe surgeries. In addition, the effectiveness of a checklist will depend on the ability of the institution's leaders to implement it, and on the adaptation measures needed for each checking instrument (20)(21) .
In this context, it is recommended including contents related to patient safety in the undergraduate and postgraduate nursing courses, as well as the training in health services (22) , since the checklist may serve as an