Introducing new surgical devices into the operating room (OR) can serve as a critical opportunity to address patient safety. The effectiveness of OR briefings to improve communication, teamwork, and safety has not been evaluated in this setting.
Ariadne Labs and Johnson and Johnson (J&J) collaborated to develop and assess an intervention including a Device Briefing Tool (DBT) and novel multidisciplinary team training for clinicians (surgeons and nurses) around the introduction of a new device in the OR. J&J sales representatives trained clinicians to use the DBT, a communication tool to improve patient safety when a new device is used for the first time. Surveys were administered to representatives (n = 10), surgeons (n = 15), and nurses (n = 30) at the baseline, after trainings, and after using the DBT in an operation at six different Thai hospitals.
Familiarity with the Surgical Safety Checklist (SURGICAL SAFETY CHECKLIST) varied but increased post-training. Regarding trainings, 90% of representatives felt they very much or completely met all learning objectives but 50% felt only slightly prepared to train clinicians on using DBT. Post-training, clinician confidence in using a new device rose from 47 to 85%. Regarding the DBT, 90% of clinicians felt confident using it and reported they were very likely to use it in the future. Overall, over 90% of all clinicians and representatives felt safe having surgery in their hospitals.
There is high acceptability and feasibility of the multidisciplinary trainings and the DBT among representatives and clinicians, albeit in a limited number of participants from a small number of institutions.
The introduction of new surgical devices in the operating room can serve as a critical opportunity to address patient safety. A 2010 report from Quality Safety Health Care acknowledges that new devices are often associated with unforeseen risks. The report posits that regulations and staff training (with ongoing surveillance and local customization) are vital in ensuring the safety of new devices and technologies.
1The Society for American Gastrointestinal and Endoscopic Surgeons (SAGES) also offers guidelines for the introduction of new technology and devices. SAGES emphasizes that to protect their patients, surgeons should demonstrate the highest level of professionalism and exercise self-assessment and self-regulation when introducing new technology and devices in their practice. Most recently, the growth of robotic surgery has highlighted the need for more standardized training around new technology and devices.
- Mytton O.T.
- Velazquez A.
- Banken R.
- et al.
Introducing new technology safely.
Qual Saf Health Care. 2010; 19: i9ei14
2Studies show that practicing surgeons lack systems that support longitudinal learning of surgical knowledge and skills. Specifically, with respect to new technology and devices, the significant issues of limited time and financial resources can serve as deterrents to surgeons gaining the experience and expertise needed for safe use. To achieve patient safety and provide cost-effective care, there is growing support for hospitals and now device manufacturers to financially support surgeons who seek to use coaching to gain skills and expertise regarding new technology and devices.
- Stefanidis D.
- Fanelli R.D.
- Price R.
- et al.
SAGES (Society of American Gastrointestinal and Endoscopic surgeons) guidelines for introduction of new technology.
SAGES Guidelines Committee, 2014
Date accessed: May 11, 2018
3Much work remains as there is still extreme variability in the way that devices and device introduction is dealt with by governments around the world.
- Pradarelli J.C.
- Thornton J.P.
- Dimick J.B.
Who is responsible for the safe introduction of new surgical technology?: an important legal precedent from the da vinci surgical system trials.
JAMA Surg. 2017; 152: 717-718
Prior research has shown the value of preoperative briefings and surgical team trainings in reducing the number of nonroutine events in an operation and in improving teamwork and communication among operative teams.
- Einav Y.
- Gopher D.
- Kara I.
- et al.
Preoperative briefing in the operating room: shared cognition, teamwork, and patient safety.
Chest. 2010; 137: 443-449
- Makary M.A.
- Holzmueller C.G.
- Thompson D.
- et al.
Operating room briefings: working on the same page.
Jt Comm J Qual Patient Saf. 2006; 32: 351-355
- Arriaga A.F.
- Gawande A.A.
- Raemer D.B.
- et al.
Pilot testing of a model for insurer-driven, large-scale multicenter simulation training for operating room teams.
Ann Surg. 2014; 259: 403-410
7In addition, studies have shown that cognitive aids improve patient safety by countering the effects of stress, ineffective teamwork, and inability to recall all evidence-based actions, which are required in response to emergencies and/or other rare events.
- Nawaz H.
- Edmondson A.C.
- Tzeng T.H.
- et al.
Teaming: an approach to the growing complexities in health care: AOA critical issues.
J Bone Joint Surg Am. 2014; 96: e184
- Hepner D.L.
- Arriaga A.F.
- Cooper J.B.
Operating room crisis checklists and emergency manuals.
Anesthesiology. 2017; 127: 384-392
9Ariadne Labs, with its expertise in surgical safety, and Johnson and Johnson (J&J), with its expertise in technical safety of devices, forged a new partnership to address the risks to patient safety associated with the introduction of new surgical devices in the operating room. Together, we worked to develop and test the feasibility of a novel intervention that includes 1) a Device Briefing Tool (DBT) designed to improve the safety and quality of first-time device use in operating rooms and 2) a scalable multidisciplinary team training curriculum to use the DBT. The goal of our intervention is both to improve the safety and quality of use of new devices and increase surgeons’ familiarity and comfort with team briefings before commencing an operation. The DBT is intended to be incorporated into the team briefing which is an important part of the WHO Surgical Safety Checklist.
- Webster C.S.
Checklists, cognitive aids, and patient safety.
Br J Anesth. 2017; 119: 178-181
We hypothesize that a multidisciplinary training of surgeons and nurses by J&J sale representatives will improve their confidence with using a new device.
Study design and methods
Our team included four members from Ariadne Labs (two academic surgeon-researchers, one surgery resident, and one PhD public health senior program manager—W.B., J.H., J.L., and R.S.) and two physicians (C.L. and S.P.) from the J&J Medical Safety Organization. The Medical Safety Organization is an independent organization within J&J which is free of potential commercial or development portfolio bias. It provides independent and objective decision-making and accountability on patient safety issues.
In Thailand, we identified six hospitals to serve as pilot sites. Within these hospitals, J&J and Ariadne staff identified teams of surgeons and nurses to participate in the pilot study. The goal was to create a multidisciplinary training opportunity where J&J representatives could train surgeons and nurses together. Surgical technicians do not appear to be significantly utilized in Thai operating rooms and thus were not included in this training. Thailand was chosen as a study site given significant pre-established collaborations between J&J and several Thai hospitals focused on improving patient safety. Given the short timeline of this study, having pre-established stakeholder support and buy-in greatly facilitated the efficiency and efficacy of our work.
Study context and participants
The Thai pilot hospitals were all teaching hospitals and considered tertiary referral centers. There was a mix of specialties represented: ranging from general surgery, hepatobiliary pancreas, surgical oncology, colorectal, and transplant. The hospitals ranged in size from 500 to 2000 inpatient beds.
The representatives who served as the key trainers during the multidisciplinary trainings on the use of the DBT all had university degrees (common areas of concentration: life science, medical technology). They understood English but were not fluent speakers. There was a variable range of time of employment at J&J from 1 to 10 y.
The creation of our DBT and training materials was a multidisciplinary and iterative process. This process involved generation of items for inclusion by expert consensus followed by review and feedback by practicing surgeons and nonclinician safety experts. A revised 4-item version of the DBT was then shared with J&J and additional practicing surgeons (n = 5) outside of Ariadne Labs. The additional practicing surgeons all practice in the United States and come from the following specialties: General Surgery, Trauma Surgery, and Surgical Critical Care. This was a convenience sample of surgeons well versed in quality improvement and global health and known by the principal investigator and another member of the research team. Overall, the key feedback from this rapid cycle feedback process included the following: 1) the DBT should be kept short and manageable, given the significant time constraints within the operating room. 2) The DBT should include the following: recognition of the moment when a new device will be used, confirmation that the J&J Optimized Device Performance guide was reviewed, and inclusion of a statement by the surgeon to ensure that anyone with concerns or questions speaks up. The standard and pictorial versions of the DBT are available in the Appendix. The Optimized Device Performance guide is a resource tool developed and disseminated by the Johnson & Johnson Medical Device Companies which is intended to help surgeons use their new device in accordance with the Instructions for Use. The Optimized Device Performance guide and Instructions for Use provide information on the safe and efficacious use of the device. It identifies key procedural risks, warnings and precautions, and appropriate risk mitigation strategies, again intended to help surgeons to achieve optimized device performance and procedural outcomes. For this collaboration, the Optimized Device Performance guide was specific to the sealing device that was being launched.
Although the DBT was designed to be used for any device, the device used in the pilot study was new surgical large jaw tissue sealer intended for open surgical procedures where vessel ligation and division is needed.
In addition to the creation of the DBT, the Ariadne team also developed a package of training materials that could be used for future implementation to address the needs of both surgeons and nurses. The package includes a standardized curriculum and accompanying presentations for training of the representatives and for representatives to use when training clinicians. The Ariadne Team also created a DBT training video that provides an overview of the Ariadne/J&J collaboration, a primer on the Surgical Safety Checklist and importance of patient safety in surgical care, an introduction to the DBT and the Optimized Device Performance guide, and a mock simulation of the DBT in a high fidelity simulated operating room with a human patient simulator. Feedback was continuously incorporated from our J&J collaborators and their Thai Patient Safety coordinator (a native Thai speaker) was able to provide Thai subtitles.
The training curriculum presentation and video were then used by our principal investigator Dr Joaquim Havens (a practicing surgeon and researcher) to train all 10 representatives using a web-based training. Dr Havens does not speak Thai and so a local J&J collaborator, based in Bangkok, translated the training. Subsequently, these 10 representatives used our training curriculum presentation and video to train 15 surgeons and 30 nurses over the course of 16 team trainings before their use of the DBT in the operating room. The surgeon specialties represented included General Surgery, Transplant Surgery, Vascular Surgery, and Surgical Oncology. All nurses were operating room nurses. While we did not record exact dates of the trainings and the first time of use in the operating room, the overall period was approximately 4 mo, between January 2018 and April 2018. We also worked to ensure that we timed the trainings to take place as close to the first use as possible. Thus, all trainings occurred the day before or on the day of first use in the operating room.
To assess our intervention (of the DBT and multidisciplinary trainings), we administered surveys to all representatives and clinicians participating in the DBT trainings. All surveys are available in the Appendix. The goals of the surveys were to understand the perceptions of representatives and clinicians regarding the training process and capture feedback from representatives and clinicians that could be used to improve the DBT. Surveys were given to representatives at the baseline, after representatives training by Ariadne Labs team, after representatives' training of clinicians, and after representatives’ observation of clinicians using the DBT in the operating room. Survey was given to clinicians at the baseline (before training), after training, and after the first operation when they used the DBT. The overall period across which the surveys were administered was from January 2018 to April 2018 and covered 15 cases (wherein one operation involved two surgeons).
The methodology for survey development included creation of key domains to be covered in each of the surveys. Domains included evaluation of current training; attitudes on Optimized Device Performance guide; knowledge of, familiarity with, and attitudes about Surgical Safety Checklist; attitudes on patient safety; and feedback on proposed training model and DBT. We then drafted questions for each of the domains and used Likert scales for most questions. Feedback on survey questions was obtained through semistructured interviews and focus groups. Four rounds of feedback were used to generate the final surveys that captured feedback from surgeons (n = 8), public health experts (n = 5), and a qualitative research specialist and research methodologist.
We report simple counts and frequencies of survey responses. Because the sample of respondents is small, with low statistical power, and not representative of a larger clinical population, we did not conduct inferential statistics or significance tests. All descriptive statistics were calculated using SAS 9.4.
The study was approved by Institutional Review Board at the Office of Human Research Administration at the Harvard T.H. Chan School of Public Health.
Statistics—trainings and surveys
Eleven representatives were trained and 10 representatives completed all surveys (baseline, post-rep training, postclinician [surgeon and nurse] training, and postsurgery). Sixteen surgeons participated, 15 completed the baseline and postclinician training surveys, and 14 completed the postsurgery survey. Thirty nurses participated, 30 completed the baseline survey, and 29 completed the postclinician training and postsurgery surveys.
Reactions of representatives and clinicians
Overall, 90% all participants reported that the goals of the collaboration were clear through the training, the training principles and objectives were clear, and the trainings very much or completely met all learning objectives. However, when asked “following training, how prepared do you feel to train clinicians using the DBT?,” three representatives felt very prepared, two felt prepared, and half (or n = 5) felt only slightly prepared.
Clinicians were asked about the trainings regarding new devices they received in the past and what their perceptions were regarding the usefulness of these past trainings. The data are captured in Table 1 and show that many formats were used in prior new device trainings and simulations are perceived to be the most useful by clinicians. After our trainings, clinician confidence in using new devices rose (as seen in Table 2). There was no notable difference in clinician confidence based on being trained by representatives that felt “prepared to train clinicians” versus those that did not.
Table 1Formats used in current new device trainings.
Table 2Clinician confidence before and after training.
Finally, over 90% of clinicians feel confident about using the DBT, are very likely to use the DBT the next time they use a new device, and want the DBT used if they have surgery. Over 80% of clinicians felt that the length of the DBT was correct, the time to complete the DBT was correct, and the DBT fit well with their workflow. In terms of timing to use the DBT, 64% of clinicians want to use the DBT right before entering the operating room and 27% want to use the DBT in the operating room before starting their case.
Effects on local practices
Baseline familiarity with the Surgical Safety Checklist varied across representatives and clinicians but increased after training (Table 3). Representatives appeared to have the lowest familiarity with the SURGICAL SAFETY CHECKLIST at the baseline. In addition, there were some participants that stated they had never heard of the Surgical Safety Checklist, even after the training. The biggest barriers to Surgical Safety Checklist use among clinicians are captured in Table 4. Overall, the lack of perceived need and the belief that the Surgical Safety Checklist was too time-intensive were most frequent complaints. Of note, after training, the number of nurses expressing a lack of perceived need regarding the Surgical Safety Checklist dropped from 41% (n = 19) at the baseline to 10% (n = 22) after training. Despite variable familiarity with and perceptions of the Surgical Safety Checklist over 90% of clinicians and representatives would want the Surgical Safety Checklist used if they themselves were having surgery.
Table 3Familiarity with surgical safety checklist.
Table 4Barriers to surgical safety checklist use.
Impressions of the device briefing tool
The data are captured in Table 5 and show that a clear majority of clinicians felt that the single most important reason to use the DBT was that it “makes the operating room team aware that a new device is being used.” Overall, clinicians expressed their support for the DBT, stating that it was easy to use, easy to understand, contained helpful information, better prepared the team to use a new device, promoted more confidence in the operating room, and ensured a shared understanding between surgeons and nurses.
Table 5Clinician rankings of most important reasons to use DBT.
There is growing interest in improving the safety of the introduction of new surgical devices in the operating room. Concurrently, there is increased research on the use of briefings and team trainings to improve teamwork and communication in the operating room. Building on prior experience with the development and implementation of SURGICAL SAFETY CHECKLIST worldwide, Ariadne Labs collaborated with J&J to develop and test the feasibility and acceptability of a novel, potentially scalable intervention. The intervention included a multidisciplinary training curriculum which can be effectively led by a corporate sales force and a DBT to be used by surgeons and nurses during the introduction of a new device in the operating room. We hypothesized that a multidisciplinary training of surgeons and nurses by representatives and the use of the DBT would improve their confidence with using a new device and promote improved teamwork and communication in the operating room.
Our findings support the acceptability and feasibility of a multidisciplinary training and introduction of the DBT into operating rooms when using a new surgical device. First, the DBT itself was uniformly viewed as useful and able to fit within existing workflows. Second, the multidisciplinary training and the DBT were successful in raising confidence in clinicians dealing with a new device introduced in the operating room. Third, the representatives gained more awareness about safety and the Surgical Safety Checklist through participating in trainings and through teaching teams about the DBT. However, some participants stated that they never heard of the Surgical Safety Checklist even after the training and thus future trainings might need to further emphasize the role of the Surgical Safety Checklist. However, overall not only did our intervention (DBT + training) directly improve confidence in use of a new device but it also suggests that industry (specifically representatives) can be a positive resource in the patient safety movement.
Although the pilot demonstrated usability and feasibility, the DBT can and should be improved. Additional testing will allow refinement of language and further improvement in the integration of the DBT with the Surgical Safety Checklist. Much of the value of the DBT likely lies in its ability to stimulate questions from the operative team about the new device-making certain the device itself is ready to use and fully functional.
Bringing the DBT to the operating room—sale representatives as means of implementation
In this feasibility and acceptability trial, we leveraged the established role and access of the sales representatives to trains surgeons and nurses. Other studies might employ different types of trainers. While representatives in our study were largely very positive about the training they received, half did not feel well prepared to train clinicians. Furthermore, our Ariadne Labs team conducted six onsite observations of the representatives while they trained clinician groups. The representatives were professional, highly prepared, and engaged well with both surgeons and nurses. However, from our survey results, it was notable that only 50% of representatives stated that they felt prepared to train clinicians, although the vast majority of clinicians found the trainings by the representatives to increase their confidence in using the DBT. If we were to speculate about the etiology of this, it was notable that the representatives comfort level appeared to be much greater when having one-on-one sessions with the clinicians versus when presenting to large groups. And thus, their perceived lack of preparedness might be reflective of a lack of confidence with training large groups and/or public speaking. Given that the representatives are well respected, able to function with significant autonomy, and have access to large numbers of surgeons and nurses; it appears that continuing to use them as trainers has significant potential. However, to further improve this delivery model, trainings might need to be adapted to further emphasize patient safety (versus technical device safety alone) and instruction for representatives that specifically focuses on group teaching/public speaking. Overall, while representatives have been focused on providing training regarding the technical aspects of a new device, our intervention started to explore the possibilities of expanding their role to also promoting safety and culture and improvement. Of note, there was no formal auditing of the training provided to the surgeons and nurses by the representatives other than the six observations. However, one of our JNJ collaborators was present for all trainings to answer questions and provide general quality control. In the future, a more formal auditing process could potentially yield more information to better gauge the needs of surgeons and nurses and further customize/improve future trainings.
Our onsite observations provided the opportunity to reflect and develop certain key best practices that could inform future roll-outs of briefing tools and multidisciplinary trainings. The proposed best practices are summarized in the following:
- •Provide options for trainings: surgeons and nurses separately or together.
- •Ensure training on DBT near the time of use in an operation.
- •Designate time for debriefings following all training sessions (of representatives and clinicians) to focus on what went well and what can be improved for future sessions.
- •Be open to ongoing development to adapt the tool and training based on feedback from participants.
- •Promote local customization of the tool and training to best meet local needs.
Our study has several limitations. First, given constraints of time and resources, we were only able to measure acceptability and feasibility of our training and device briefing tool, with this study population versus any other patient or clinical outcomes. Second, given the small sample sizes of representatives and clinicians, our data analysis is strictly descriptive in nature with no inferential statistical analysis. Third, while Table 2 shows surgeon's perceptions of their confidence with the new devices before and after use of the DBT, we did not perform any audits of the surgeon's actual familiarity and frequency of use with the sealing device before implementation of the DBT. Varying levels of familiarity with the device from prior use, research, or continuing medical education might have influenced surgeon/nurse attitudes toward the necessity of DBT use. Of note, this tool is meant to be used when teams are not familiar with the new device. It's important to use the DBT if even one surgical team member is new to using the device, but if all are familiar, we foresee that the tool is less necessary. Fourth, the survey questions asking about the use of the Surgical Safety Checklist in Thai operating rooms likely underestimated both understanding and use because we did not fully understand the local context. Specifically, our survey data showed low to medium awareness of the Surgical Safety Checklist before and after our training. This is in line with past data that while Surgical Safety Checklists have been shown to reduce morbidity and mortality worldwide,
10their implementation is highly variable.
- Haynes A.B.
- Weiser T.G.
- Berry W.
- et al.
A surgical safety checklist to reduce morbidity and mortality in a global population.
N Engl J Med. 2009; 360: 491-499
- Mayer E.K.
- Sevdalis N.
- Rout S.
- et al.
Surgical checklist implementation project: impact of variable WHO checklist compliance on risk adjusted clinical outcomes post-national implementation.
Ann Surg. 2015; 263.1: 58-63
- Berry W.
- Haynes A.B.
- Lagoo J.
The surgical checklist: it cannot work if you do not use it.
JAMA Surg. 2016; 151: 647
- Kasatpibal N.
- Senaratana W.
- Chitreecheur J.
- Chotirosniramit N.
- Pakvipas P.
- Junthasopeepun P.
Implementation of the World Health Organization surgical safety checklist at a university hospital in Thailand.
Surg Infect (Larchmt). 2012; 13: 50-56
14However, onsite observations and discussions with representatives and clinicians at many of the Thai hospitals provided further context on this issue. Representatives and clinicians noted that while many seem to be unfamiliar with the Surgical Safety Checklist terminology, they implement a “timeout” in the operating room routinely, which appears to include key elements of the Surgical Safety Checklist and could be helpful in promoting speaking up and teamwork. Thus, in the future, while there is always room for improved Surgical Safety Checklist implementation; there appears to also be the need for greater adaptation of our survey questions to better match local language and context. Fifth, there was a significant pre-established collaboration between J&J and the selected hospitals that focused on improving patient safety culture. This pre-established relationship could have affected the results of the present study and there were no specific ways that our research team attempted to control for that influence.
- Treadwell J.R.
- Lucas S.
- Tsou A.Y.
Surgical checklists: a systematic review of impacts and implementation.
BMJ Qual Saf. 2014; 23: 299-318
Our primary aim to assess the acceptability and feasibility of our novel and potentially scalable intervention (a multidisciplinary new device training and the DBT) was met. There was high acceptability and feasibility of the training and DBT by both representatives and clinicians. In the past, representatives have focused heavily on only the technical aspects of new surgical devices and our intervention broadens their scope to include improving safety and quality of care. However, further work to better prepare representatives to train surgeons and nurses in patient safety and quality improvement is necessary to fully leverage and empower representatives to become agents of change around safety culture. Our work has also highlighted the importance of local customization of our tools and/or trainings to improve feasibility and acceptability of our intervention. Thus, in the future, multiple training modalities might need to be offered to ensure representatives feel more prepared and/or surgeons and nurses might need to be trained separately. We utilized feedback and iteration in the development of the DBT and all training materials and ensured that we were garnering feedback from multiple stakeholders and end users throughout the process. In the future, we propose to build on this foundational work and consider further interdisciplinary collaborations to improve teamwork and communication in operating rooms worldwide.
Ariadne Labs is a joint center between Brigham and Women's Hospital and the Harvard T.H. Chan School of Public Health. Our mission is to create scalable health care solutions that deliver better care at the most critical moments in people's lives, everywhere.
The authors would also like to acknowledge two members of the Ariadne Labs team for their significant contributions: Natalie Henrich for survey development, Kate Miller for data analysis design and data visualization, and Amy Karlage for manuscript editing.
Authors' contributions: J.L. worked on the initial manuscript draft, data analysis, and synthesis of feedback from other authors to create the final manuscript. R.S. provided significant guidance with manuscript development and data analysis. W.B. targeted guidance with manuscript development and focus on implementation science. A.G. targeted guidance with manuscript development and focus on implementation science. C.L. provided feedback on manuscript drafts and expertise on industry perspective around new devices and patient safety. S.P. provided feedback on manuscript drafts and expertise on industry perspective around new devices and patient safety. J.H. provided significant guidance with manuscript development and data analysis and provided targeted expertise on global surgery initiative development.
- Appendix 1
- Appendix 2
- Appendix 3
Ariadne Labs collaborated with Johnson and Johnson Medical Devices, USA on this project and received funding from them for this work. In regard to this collaboration, Johnson and Johnson provided input on the initial study design and assisted with editing for language in this manuscript. Johnson and Johnson had no control over data analysis or the results being reported here.
- Introducing new technology safely.Qual Saf Health Care. 2010; 19: i9ei14
- SAGES (Society of American Gastrointestinal and Endoscopic surgeons) guidelines for introduction of new technology.SAGES Guidelines Committee, 2014 (Available at:)https://www.sages.org/publications/guidelines/guidelines-introduction-new-technology-techniques/Date accessed: May 11, 2018
- Who is responsible for the safe introduction of new surgical technology?: an important legal precedent from the da vinci surgical system trials.JAMA Surg. 2017; 152: 717-718
- Preoperative briefing in the operating room: shared cognition, teamwork, and patient safety.Chest. 2010; 137: 443-449
- Operating room briefings: working on the same page.Jt Comm J Qual Patient Saf. 2006; 32: 351-355
- Pilot testing of a model for insurer-driven, large-scale multicenter simulation training for operating room teams.Ann Surg. 2014; 259: 403-410
- Teaming: an approach to the growing complexities in health care: AOA critical issues.J Bone Joint Surg Am. 2014; 96: e184
- Operating room crisis checklists and emergency manuals.Anesthesiology. 2017; 127: 384-392
- Checklists, cognitive aids, and patient safety.Br J Anesth. 2017; 119: 178-181
- A surgical safety checklist to reduce morbidity and mortality in a global population.N Engl J Med. 2009; 360: 491-499
- Surgical checklist implementation project: impact of variable WHO checklist compliance on risk adjusted clinical outcomes post-national implementation.Ann Surg. 2015; 263.1: 58-63
- The surgical checklist: it cannot work if you do not use it.JAMA Surg. 2016; 151: 647
- Implementation of the World Health Organization surgical safety checklist at a university hospital in Thailand.Surg Infect (Larchmt). 2012; 13: 50-56
- Surgical checklists: a systematic review of impacts and implementation.BMJ Qual Saf. 2014; 23: 299-318
Published online: August 22, 2019
Accepted: May 30, 2019
Received in revised form: April 6, 2019
Received: November 5, 2018
© 2019 Elsevier Inc. All rights reserved.