Implementation of a surgical safety checklist in Brazil : cross-sectional study

Rev Bras Enferm. 2021;74(2): e20190874 http://dx.doi.org/10.1590/0034-7167-2019-0874 5 of ABSTRACT Objective: to identify the implementation process of the World Health Organization Surgical Safety Checklist in Brazilian hospitals. Methods: this is a cross-sectional study with 531 participants during a Congress of Perioperative Nursing, promoted by the Brazilian Association of Operating Room Nurses, Anesthetic Recovery and Material and Sterilization Center, in 2017. Results: among the nursing professionals included, 84.27% reported the checklist implementation in the workplace. Regarding daily application in the Sign-in stage, 79.65% of professionals confirmed patient identification with two indicators; in the Timeout stage, 51.36% of surgeries started regardless of confirmation of one of the items. In the Sign-out stage, 69.34% of professionals did not count or occasionally counted the surgical instruments and suture needles, and only 36.36% reviewed concerns about postoperative recovery. Conclusion: this study identified needs for improvements in applying the checklist in the Brazilian reality, to guarantee safer surgical procedures. Descriptors: Nurses; Patient Safety; Checklist; Perioperative Care; Risk Management.


Implementation of a surgical safety checklist in Brazil:
cross-sectional study Implementação

INTRODUCTION
The number of surgeries has progressively increased over the years, with an estimated 312,93 million procedures worldwide (1) . In this context, the operating room (OR) is a complex environment in which professionals need to work in teams to guarantee care quality and safety of for patients (2) .
Faced with morbidity and mortality rates associated with surgeries, in 2008, the World Health Organization (WHO) launched the "Safe Surgery Saves Lives" program, which proposed applying a three-step surgical safety checklist (Sign-in, Time-out, and Signout). Before beginning the surgery, the steps include checking the materials and equipment required, patients' airway conditions prior to anesthesia, staff member confirmation, critical moments of the anesthetic-surgical procedure, and antibiotic prophylaxis. Before leaving the OR, the steps included verifying possible failures occurred during the procedure, anatomopathological sample, review of patients' needs for postoperative recovery, as well as gauze, compress and needle count (3) .
In 2013, the Brazilian Ministry of Health approved a protocol for safe surgery, which guides the application of a checklist in all health establishments that perform procedures, inside or outside the OR, involving an incision in the human body or introduction of endoscopic equipment by any health professional. This action was aimed at preventing and reducing the incidence of adverse events, enhancing patient safety assurance (4)(5) .
It should be emphasized that applying the checklist in health institutions reduces the number of postoperative complications, such as surgical site infection and reoperation, as well as a decrease in mortality associated with the surgical procedure (6)(7) . Additionally, application of the checklist during surgery improved communication among professionals and increased safety perception related to the provided care (2,8) .
Thus, the Brazilian Association of Operating Room Nurses, Anesthetic Recovery and Material and Sterilization Center (SO-BECC -Sociedade Brasileira de Enfermeiros de Centro Cirúrgico, Recuperação Anestésica e Centro de Material e Esterilização) develops a mission of collaborating with technical-scientific development and dissemination of best practices for perioperative nursing in Brazil, sought to identify the WHO Surgical Safety Checklist implementation by nursing staff members in different hospitals in Brazil.

OBJECTIVE
This study aims to identify the implementation process of the WHO Surgical Safety Checklist in Brazilian hospitals.

Ethical aspects
Nursing professionals attending the event and who worked at an OR were invited to participate in the study, and they agreed after signing the Informed Consent Form (ICF). The study was approved by a Research Ethics Committee.

Study design, setting and sample
This is a quantitative and cross-sectional study. Data collection was performed in September 2017 during the 13 th Brazilian Congress of Nursing in Operating Room, Anesthetic Recovery, Anesthetic Recovery and Material and Sterilization Center, conducted by SOBECC.
A non-probability sampling of nursing professionals was selected, with an inclusion of 531 nurses.

Data collection
We used an instrument composed of 20 closed questions based on the WHO Surgical Safety Checklist to collect data. Moreover, sociodemographic characteristics and professional data were collected. The instrument was submitted to face and content validity by three experts on perioperative nursing. The experts agreed with the content proposed and made minor rephrasing suggestions.
A pilot test was conducted with ten subjects prior to the actual collection period and not included in the final analysis sample, to verify the suitability of the instrument and the proposed collection method. On this occasion, minor adjustments were made in the question formulation, to improve comprehension.
The research subjects were guided into an auditorium, and the instrument questions were projected on a screen. Participants could select the answer of their choice through an electronic voting system, which released preliminary results after a 60-second voting period. The information from this research served as a guide for further discussions at the event, with OR and quality experts.

Data analysis
Data were analyzed descriptively and utilizing absolute numbers and percentages.

RESULTS
The number of respondents varied between 531 and 280 subjects among the responses received per item, and so, the number of responses received for each assessed item is presented in the following tables. Table 1 shows that participants came from all regions of the country, with emphasis on the Southeast (54.8%). They were between 31 and 40 years old (45.4%) and worked in an OR between one and five years (31.3%) ( Table 1).
Among the assessed professionals, 51.18% reported working at a large institution, 34.05% of institutions were private, and 58.70% of sites did not have quality accreditation (Table 2).
Overall, 84.27% of participants reported implementing the WHO Surgical Safety Checklist, and 74.1% of professionals made changes in the material proposed by WHO.
Concerning the execution of items per step, according to the WHO proposal, it was observed in the Sign-in stage that none of the assessed items was fully verified, as can be seen in Table 3.
For the Time-out stage, it was found that this stage is performed mostly (74.77%) by a nursing assistant or technician, a professional characterized as circulating in the room, and that nurses are the ones who perform this step in only 24.08% of situations.  In the Time-out stage, more than half of the sample stated that the presence of all staff members is only occasionally confirmed, and that the surgery is occasionally started without confirmation of one of the Time-out items for 51% of the sample. Patient identification, surgical site and procedure before its onset occur only occasionally in 46.09% of the sample (Table 4).
In the Sign-out stage, it is noteworthy that although 39.54% of professionals occasionally perform surgical instrument and suture needle counts, the most report always performing the counting of compresses and gauzes. As for postoperative management and recovery concerns of patients, 50.51% of participants occasionally review these concerns with an anesthesiologist (Table 5).
When questioned about the importance of implementing the checklist, 393 (99.49%) professionals believe that applying checklist increases the safety of patients undergoing surgeries. However, when completing the checklist, only 52 (13.27%) believed that they implemented 100% of the steps and items; 174 of Implementation of a surgical safety checklist in Brazil: cross-sectional study Poveda VB, Lemos SL, Lopes SG, Pereira MCO, Carvalho R.
the Sign-in was performed in 64.4% of procedures, Time-out, in 34.4%, and Sign-out, in 64.3% of surgeries (7) . On the other hand, it should be noted that applying the checklist in the three stages proposed was associated with a lower risk of postoperative bleeding, reduced intraoperative transfusion, and a reduction in the number of infections due to antibiotic administration before surgical incision (12) .
Thus, it is important to mention that only implementing a safe surgery checklist does not guarantee its adequate performance, since professionals' perceptions and organizational factors can influence the appropriate use of a care tool.
The inadequate use of the checklist was associated to a lack of understanding by professionals about the stage's appropriate execution moment; the rush of surgeons to start the procedure, raising the impression that pausing for checklist delays the work development. Furthermore, not all professionals were attentive during the application time of the checklist (13) . On the other hand, using the safe surgery checklist improved communication and teamwork among professionals such as increased safety perception about patients, because all practitioners have the information about patients and features for care (14) .
Therefore, health organizations play a fundamental role in the educational orientation of health staff professionals, offering support for implementing care tools in daily routines and showing the importance of using safety measures (15)(16) . The successful implementation of the checklist was associated to training and learning material promotion, leadership development for continuous monitoring and auditing the checklist use, clarity in the role of each professional in the staff and support for analyzing actual effectiveness of implementing the checklist (13,17) .
Since the daily application of the checklist in an OR has a positive impact on communication among professionals (surgeons, anesthesiologists, nurses) and safety in the OR, there are changes in the perceptions of teamwork and safety climate, thus constituting aspects that may influence a reduction in postoperative morbidity (2) .

Study limitations
This study demonstrates a limitation in absence of analyzing the causes of not completing the checklist items by professionals. Thus, it is important to develop future studies, which assess the limiting factors for correct execution of the checklist, as well as an analysis of the damage and complications generated by inappropriate use.

Contributions to nursing and health
The results of this study demonstrate a sample of the national reality, which can collaborate for implementing improvements by surgical staff, health institutions and responsible government agencies, in addition to pointing out future directions in terms of education and training to be conducted by SOBECC.

CONCLUSION
This study enabled us to identify that, despite recognizing the importance of the checklist for patient safety on the part of professionals, there are several fragile points in applying the

DISCUSSION
The results demonstrated that although professionals recognize the importance of applying the checklist for patient safety, incomplete application of items occurs at all stages, which may favor adverse event occurrence. In this context, since the beginning of development safe surgery checklist, literature has shown that implementation of this tool provided positive outcomes in the postoperative period. Using the safety checklist in eight health institutions showed a reduction in postoperative complications, such as surgical site infection and reoperation, from 11% to 7%, in addition to a decrease from 1.5% to 0.8% of mortality associated with the surgical procedure (9) .
In this regard, a retrospective study analyzing 233 cases of damage to patients, in ten years of otorhinolaryngological procedures before complete the safe surgery checklist implementation, pointed out that 84.3% of injuries were associated with the care offered, mainly being related to surgical technique, unnecessary procedures, retention of foreign bodies and infection (10) .
A survey showed that more than half of participants did not apply the checklist. The same evidence was observed in other studies, whose completeness of checklist steps varied between 34% and 68% (7,11) . Assessment of 565 surgical procedures, performed in five hospitals in England, also verified the incomplete application of the checklist. Carrying out the Time-out step occurred in 64% of procedures and the Sign-out step in 68% of surgeries (10) .
When analyzing Time-out items, staff was incomplete in 43% of procedures; in 10% of surgeries patient identification and procedure was not confirmed; in 29% of procedures there was blood loss, and in 15% of cases antibiotic prophylaxis was not assessed. At the Sign-out stage, 36% of procedures did not review concerns about recovery and management of postoperative patients (11) .
Another investigation observed that the checklist's three steps were applied in only 62.1% of surgical procedures, and incomplete checklist execution was related to a 16.9% increase in the risk of complications after surgery. When analyzed individually,