Adherence to the objectives of the Safe Surgery Saves Lives Initiative: perspective of nurses

ABSTRACT Objective: to measure the adherence to the objectives of the Safe Surgery Saves Lives Initiative in surgical centers from the perspective of nurses. Method: cross-sectional study, developed through an online survey via the Google Forms® platform. The study participants were 220 nurses from surgical centers in different regions of Brazil. The data were collected through a socio-professional characterization form and a questionnaire in which the participants indicated their level of agreement in relation to the fulfillment of the objectives of the Safe Surgery Saves Lives Initiative. Data analysis was performed using descriptive statistics. Results: objective 1, The team will operate on the correct patient at the correct site, presented the highest levels of total agreement (n = 144; 65.5%) and partial agreement (n = 52; 23.6%). Objective 10, Hospitals and the public health systems will establish routine surveillance of surgical capacity, volume and results, obtained the lowest percentages of total (n = 69, 31.4%) and partial agreement (n = 81, 36.8%). Conclusion: adherence to the objectives of the Initiative is adequate, but there are weaknesses, especially in relation to the prevention of never events.


Introduction
Surgical centers are considered to be complex and high-risk units, susceptible to errors and adverse events that can lead to death or complications for patients. In developed countries, the rate of major complications in surgical procedures is 3-16% and the mortality rate is 0.4-0.8%; approximately half of these events may be considered preventable. In developing countries, mortality rates of 5 to 10% are estimated in large surgeries (1) . Gutierres LS, Santos JLG, Barbosa SFF, Maia ARC, Koerich C, Gonçalves N.
In order to broaden access to research and, therefore, include non-registered nurses in the aforementioned institutions, the research link was also shared for WhatsApp ® groups and contacts to which the researchers had access and who were related to work in health/surgical centers. In total, 205 messages were sent via WhatsApp ® . The link was also shared on social networks, such as Facebook ® , LinkedIn ® and Instagram ® , reaching more than 23 thousand people, of whom 219 clicked on the link. The team will recognize and effectively prepare for lifethreatening loss of airway or respiratory function; (4) The team will recognize and effectively prepare for risk of high blood loss; (5) The team will avoid inducing an allergic or adverse drug reaction for which the patient is known to be at significant risk; (6) The team will consistently use methods known to minimize the risk for surgical site infection; (7) The team will prevent inadvertent retention of instrumentals or sponges in the surgical wounds; (8) The team will secure and accurately identify all surgical specimens; (9) The team will effectively communicate and exchange critical information for the safe conduct of the operation; and (10) Hospitals and public health systems will establish routine surveillance of surgical capacity, volume and results.
Before data collection, face and content validity was performed with three nurses from a surgical center and two nurse professors with experience in the study theme, who were not included in the study. In addition, the judges performed a pre-test to ascertain the ease/ difficulty in completing the instrument. As there were no disagreements, suggestions and difficulties in filling it out, no changes were required in the instrument.

Results
A total of 248 responses were received, but the responses of 220 nurses were considered for the study sample. Based on the inclusion and exclusion criteria, we excluded 10 participants who reported having less www.eerp.usp.br/rlae Rev. Latino-Am. Enfermagem 2019;27:e3108.
than three months of experience in surgical center, 10 questionnaires due to double participation, and eight due to incomplete items. Table 1 shows the characterization of the socio-professional profile of the sample. Gutierres LS, Santos JLG, Barbosa SFF, Maia ARC, Koerich C, Gonçalves N.
From this classification, it can be considered that objectives 1, 7 and 8 aim at the prevention of never events. Therefore, any option other than I Totally Agree (TA) indicated by the participants of this study regarding these objectives indicates a risk to patient safety.
Difficult airway access generates complications that can result in death or brain damage, which are avoidable from the assessment of the airway before anesthetic induction (21) . In Brazil, there are technologies available for the prevention of difficult airways, including simple and economical alternatives that contribute to patient safety (22) .
The prevention of risks related to adverse events is a key point in the safety of the anesthetic act. A Brazilian study presented an overview of the occurrence of Perioperative Anaphylaxis (PEOA), which is a rare allergic reaction, but with a rapid and fatal onset. The incidence varies according to the country, being 1:1,250 to 1:13,000 surgeries. The main causes are muscle relaxants, latex and antibiotics (23) .
Approximately 15% to 40% of patients who undergo surgical procedures present anemia at the time of surgery (24) . From the pre-anesthetic consultation, it is possible to reverse the anemic condition of the patient in about 15 days. Preoperative anemia is directly related to blood transfusion in the surgical procedure, which is considered the main cause of postoperative morbidity and mortality (25) .
Another important aspect is the role of the anesthesiologist in the administration of anesthetic drugs. Although intravenous drug delivery protocols have not shown major changes in the last 60 years, there is still a high rate of errors related to medication in the anesthetic act (26) .
In Santa Catarina, Brazil, a study with 61 anesthetists showed that 91.8% had already committed more than one medication administration error. The main causes were distraction, fatigue or low severity of the patient (27) . In China, a study showed omission, incorrect dosage and medication substitutions as major causes of error in anesthetic medication (28) . Incorrect identification of ampules and syringes is also one of the main causes of medication error related to the anesthetic act (29) .
In cause of morbidity and mortality in modern medical care (30) . Most SSIs are preventable, especially from the conduction of prophylactic antibiotic (31)(32) . In Brazil, the adherence rate to the use of prophylactic antibiotic therapy is 84% (33) . In Sweden, this rate is estimated at 92% (34) .
Objective 7 had an agreement rate of 84% and also referred to a never event. This result is worrying given the serious consequences of such an event on patients.
Sponge counting is a low-cost practice that requires organization and a structured method, such as a printed form (1,35) . Retention of a sponge on a surgical wound generates a gossypiboma, which is a textile matrix wrapped by foreign body reaction. It occurs mainly in the intra-abdominal area and may present fistula, abscess or mass (36) .
The incidence of gossypiboma is underreported due to medical and legal implications. According to a literature review, its occurrence rate in abdominal operations is 1:1,000 to 1:1,500. The patient often becomes asymptomatic, which also contributes to underreporting (37) . A study carried out in Pakistan has shown that the occurrence of gossypiboma occurs mainly in emergency surgeries (38) .
In Objective 8, partial and total agreement rate was of 84.5%. This finding is in line with the results of a study with 31 nursing professionals from a surgical center in São Paulo, Brazil, of which 92.9% considered the inappropriate disposal of a surgical specimen a serious adverse event (15) . In Taiwan, of the 200,345 specimens collected at a medical center, 1023 were with misidentification (39) .
Objective 9 obtained 81.4% of agreement, the second lowest index among the evaluated objectives, indicating that communication problems are very frequent in a surgical center. A Dutch study associated 11% of adverse events occurred in the operating room with relationship problems and communication failures (14) . In Brazil, the lack of communication between the medical and nursing staff represents 32% of the causes of adverse events in a surgical center (15) .
Objective 10 presented the lowest level of agreement among the analyzed objectives. The sharing of information and the socialization of indicators encourages learning from error. In addition, ongoing notification and tracking strengthens the dissemination of the safety culture and engages team members in the development of best safety practices (33) . The monitoring of results in the surgical centers is important to enable managers and professionals for decision making in the surgical center (40) .
Thus, the results of the present study contribute to evidence of the complexity of adherence to WHO recommendations in the Safe Surgery Saves Lives Initiative. In addition, the findings may help managers and health professionals in the development of strategies for patient safety in the surgical center, especially in relation to never events.
Regarding the limitations of this study, the interpretations of the results can be considered of

Conclusion
Appropriate adherence to nine of the 10 objectives of the Safe Surgery Saves Lives Initiative was found.
The objective that presented unsatisfactory adherence concerns the adoption by hospitals and health systems of routine surveillance mechanisms on surgical capacity, volume and results. Thus, it is expected that this study may subsidize the discussion of strategies to increase patient safety in the surgical center, especially in relation to health surveillance and prevention of never events.