‘It’s a State of Mind’: a qualitative study after two years’ experience with the World Health Organization’s surgical safety checklist

Based on current weaknesses in the understanding of the mechanisms, factors and positive effects involved in checklist usage, as well as a scarcity of qualitative approaches, the aim of this study was to explore surgical personnel experiences with the World Health Organization’s Surgical Safety Checklist, 2 years after implementation. Three focus group interviews were conducted with surgical personnel. An interview guide was designed to assist the interview process, comprised of broad, open-ended questions. Notes and audio recordings were fully transcribed verbatim and subsequently analysed using qualitative content analysis in order to identify emergent meaning units, categories and themes. The checklist improves confidence, team communication and sharing of critical information in the surgical team. However, informants described the occurrence of wrong-site surgery not prevented by the checklist due to preoperative wrong-site marking combined with automated checklist use in the operating room. Using the checklist as a ‘tic box exercise’ was recognized as a safety challenge by all professions, especially during routine surgery. The surgical team balances safety and effectiveness constantly in the operating room. Challenges that need to be addressed include making the Sign-in part a team effort and taking the accompanying pause in performance during the Time-out and the Sign-out, with cross-check of items, in order to avoid automated checklist use. We suggest surgical team training that includes checklist performance, in order to enhance the quality of checklist use.