This study aimed to investigate compliance with and staff perceptions of the WHO surgical safety checklist (SSC) at a multi-specialty hospital in India. Observational data found highest compliance rates during sign-in and lowest during time-out. Staff generally expressed satisfaction with SSC introduction and perceived improved teamwork, safety and reduced errors, though some felt it increased workload. The study concluded SSC compliance was variable and proposed continued monitoring and training to optimize implementation and outcomes.

1. A Study on Compliance of WHO Surgical Safety
Checklist and Perception of Operating Room Staff About
its Implementation in a Multispecialty Hospital
Roll no. 1814490010

2. Aim
To Study Compliance of WHO Surgical Safety Checklist and Perception of
Operating Room Staff About its Implementation in a Multispecialty
Hospital.
Objectives
1. To investigate the actual usage of checklist in practice.
2. To conclude whether the items on the sign in, time out and, sign out
are properly checked by operating room staff.
3. To determine perception of operating room staff regarding surgical
safety checklist.
4. To propose recommendations based on study findings.

3. RESEARCH METHODOLOGY
Introduction: This study was conducted OT in 100 bedded multi-specialty hospital in
Pune. The data was collected from 1st of September to 30th of December 2017. An
observational study to check compliance of surgical safety checklist is performed in
operation theatre.
Method of data collection
The data for the study was collected with WHO surgical safety checklist.
Type of Research:
Quantitative data was collected and analyzed in this study for addressing the research
statement in a comprehensive manner. The quantitative data comprises of the
observation based on observational checklist.
Surgical safety checklist consists of different points regarding confirmation of patient
identity, site of incision etc.

4. Nature of data collection:
Quantitative data is collected and analyzed in this study for addressing the research statement in a
comprehensive manner. The quantitative data comprises of the observation based on surgical safety
checklist filled by the operating room staff.
Type of study: Quantitative and Prospective study
Sample size: All the surgeries performed during the study period.
Study period: 1st September to 30th December.
Source of data: Data was collected through WHO surgical safety checklist to check compliance in OT of a
hospital.
Inclusion criteria: All elective surgical cases operated in OT.
Exclusion criteria: Emergency surgical cases.
Criteria of assessment: Percentage as an assessment tool for measuring compliance of SSC.The
data thus gathered and from hospital records will be compared and analysed using statistical tests and
percentages and would be presented in tabular and graphical form.

5. DATA ANALYSIS AND INTERPRETATION
Graph no. 4.1: Overall Sign in Compliance Percentage (n=96)
0
10
20
30
40
50
60
70
80
90
100
QUS 1 QUS 2 QUS 3 QUS 4 QUS 5 QUS 6 QUS 7
COMPLIANCE % 82.3 79.2 91.7 84.4 5.2 6.25 6.25
82.3
79.2
91.7
84.4
5.2 6.25 6.25

6. TIME OUT
Graph no. 4.5: Overall compliance of Confirmation of Team Members
Identity, Patient Identity, Procedure, Incision Site and Antibiotic
Prophylaxis.
0.0
10.0
20.0
30.0
40.0
50.0
60.0
70.0
80.0
90.0
100.0
QUS 1 QUS2 QUS 3 QUS5
% 72.9 75.0 93.8 30.21
72.9
75.0
93.8
30.21

7. Graph no. 4.6: Overall Compliance of Anticipated Critical Events to the
Surgeon.
0.0
10.0
20.0
30.0
40.0
50.0
60.0
70.0
80.0
a b c
QUS4
Series1 70.8 31.3 7.2
70.8
31.3
7.2

8. Graph no. 4.7: Overall Compliance with Anticipated Critical Event
Reviewed by Nursing Team and Essential Imaging Displayed.
0
10
20
30
40
50
60
70
80
90
a% b%
QUS 6 69.8 12.5
QUS 7 80.2 4.2
69.8
12.5
80.2
4.2

9. SIGN OUT
Graph no. 4.14: Overall Compliance of Nurse Verbally Confirming Name of
the Procedure, Completion of Instruments, Specimen Labelling,
Equipment Problems(n=96).
0.0
10.0
20.0
30.0
40.0
50.0
60.0
70.0
80.0
90.0
a b c d
% 81.3 76.0 41.7 7.3
81.3
76.0
41.7
7.3

10. Graph no. 4.15: Overall Compliance of Key Concerns Reviewed for Recovery
and Management of the Patient by The Surgeon, Anaesthetist and Nurses.
0
5
10
15
20
25
30
35
40
a b
percentage 40 30.3
40
30.3
Axis Title

11. Table no.4.1: Overall Satisfaction with Introduction of SSC in OT (n=22)
Sr.no QUESTION HEAD
OPINION
DISAGREE AGREE TOTAL
1 Satisfaction with introduction of SSC in OT 6(27.2%) 16(72.7%) 22
2 Satisfaction with Work environment in OT post SSC 2(9.0%) 20(90.9%) 22
TOTAL 8(18.1%) 36(81.8%) 44

12. Table no. 4.2: Operating Room Staff Opinion Regarding Wither
Surgical Safety Checklist Has Affected Workflow, Increased Burden of
Work and If It Is Time Consuming to Fill The WHO Surgical Safety
Checklist(n=22).
Sr.no QUESTION HEAD
OPINION
DISSATISFIED SATISFIED TOTAL
1
WHO SSC affected workflow in OT
1(4.5%) 21(95.4%) 22
2
It is time consuming to fill WHO SSC 2(9.0%) 20(90.9%) 22
3
SSC has increased burden of work 1(4.5%) 21(95.4%) 22
TOTAL
4(6%) 62(93.9%) 66

13. Table no. 4.3: Operating Room Staff Opinion Regarding Surgical Safety Checklist
Improved Team Work and Communication, Patient Safety, Previous Followed Measures
Were Better Than Surgical Safety Checklist and Field Included in SSC Are Appropriate
(n=22)
Sr. no QUESTION HEAD
OPINION
DISSATISFIED SATISFIED TOTAL
1 SSC improved team work and communication in OT 5(22.7%) 17(77.2%) 22
2 WHO SSC improved patient safety 1(4.5%) 21(95.4%) 22
3 Previous followed measures were better than SSC 7(31.8%) 15(68.1%) 22
4 Field included in SSC are appropriate 5(22.7%) 17(77.2%) 22
TOTAL 19(17.2%) 91(82.7%) 110

14. Table no. 4.4: Operating Room Staff Opinion Regarding Reduction in
Post- Surgery Surgical Site Infection Rate, Post-Surgery Mortality Rate
and Critical Events Anticipated During Surgery(n=22)
Sr.no. QUESTION HEAD
OPINION
DISSATISFIED SATISFIED TOTAL
1 Reduction in post -surgery surgical site infection rate 0(0%) 22(100%) 22
2 Reduction in post -surgery mortality rate 6(27.3%) 16(72.7%) 22
3 Reduction in critical events anticipated during surgery 10(45.5%) 12(54.5%) 22
TOTAL 16(24.2%) 50(75.7%) 66

15. Table no. 4.5: Opinion of OT Staff Regarding Prevention of Medical
Errors and Reduction in Unplanned Admission to ICU and IPD Post
Implementation of SSC(n=22).
Sr. no QUESTION HEAD
OPINION
DISSATISFIED SATISFIED TOTAL
1 Prevention of medical errors in operating room 3(13.6%) 19(86.3%) 22
2 Reduction in unplanned admission to ICU and IPD 8(36.3%) 14(63.6%) 22
TOTAL 11(25%) 33(75%) 44

16. Table no. 4.6: Opinion of The Operating Room Staff Regarding Number of
Display Monitors Increased Due to SSC and Surgical Safety Checklist Has
Helped in Identifying Pending Instruments Problem (n=22).
Sr.no QUESTION HEAD
OPINION
DISSATISFIED SATISFIED TOTAL
1 Number of display monitors has increased due to SSC 10(45.4%) 12(54.5%) 22
2 SSC helped in identifying pending instruments problem 1(4.5%) 21(95.4%) 22
TOTAL 11(25%) 33(75%) 44

17. Graph no. 4.18: Opinion of the Operating Room Staff Regarding Introduction of SSC Will
Decrease Medico-Legal Implications (n=22).
0.0 10.0 20.0 30.0 40.0 50.0 60.0 70.0 80.0 90.0 100.0
DISSATISFIED
SATISFIED
9.1
90.9
DISSATISFIED SATISFIED
QUS 15 9.1 90.9
Percentage of Opinion Regarding Introduction of SSC Will Decrease Medico-legal Implications
DISSATISFIED SATISFIED

18. CONCLUSION
• The highest compliance rate (91.7%) during sign in period was with anesthesia and medication check
completion. Compliance rate with patient confirmation of his/ her identity, site, procedure and consent
was (82.3%). 79.2% of the sites were marked. Compliance rate with pulse oximeter on the patient and
functioning was (84.4%).5.2% of the patient have known allergy, (6.25%) of the patient have difficult
airway or aspiration risk and (6.25%) of the patient have risk of > 500ml blood loss.
• surgical teams had introduced themselves by the name and role in (72.9%) of the operations; and in
(75%) of the cases, the patient’s name, incision site, and the procedure had been confirmed. Antibiotic
prophylaxis had been given within 60 minutes before incision in (93.8%) of the cases. For (30.2%) of
the operations, the surgeons reviewed crucial events. In the time-out period for the (70.8%) of the
cases surgeon reviewed critical events. Similarly, for the (31.3%) of the cases surgeon reviewed how
long the case will take and (7.2%) of the cases reviewed for anticipated blood loss. In the time-out
period sterility has been confirmed by the operating room nurses in (69.8%) of the cases and
equipment issues had been reviewed only in (12.5%) of the cases. Essential imaging had been
displayed at the rate of (80.2%).
• In the sign out period in the sign-out period, nurses correctly confirmed the name of the procedure
orally in (81.3%) of the cases. Instrument, sponge, and needle counts were completed and the
specimen was labeled in, (76.0%) and (41.7%), respectively. Equipment-related problems were
identified in 7.3% of the cases, and 100% of them were addressed. The surgeon, anesthetist, and
nurse reviewed the key concerns for recovery and management of the patient at the rate of (70.3%).

19. • Perception Overall satisfaction with the introduction of SSC was 72.7% and
90.9% of the operating room staff was satisfied with work environment in
operating room.
• According to 95.4% of the OT staff SSC had affected workflow and 90.9% of the
OT staff responded that SSC had increased burden of work. it is time consuming
to fill the surgical safety checklist according to 95.4% of OT staff. SSC improved
team work and communication in OT (77.2%) and had improved patient safety
(95.4%). According to 68.1% of the OT staff previously followed measures were
better than SSC and fields included in the SSC are appropriate according to
77.2%of staff.
• There was 100% positive response that post-surgery surgical site infection rate
had reduced and 72.7% post-surgery mortality rate has reduced post
implementation of surgical safety checklist. According to 54.5% of the OT staff
critical events anticipated had reduced post implementation of surgical safety
checklist. According to 86.3% of the OT staff prevention of medical errors in
operating room will increase and 63.6 % of the staff responded that there was
reduction in unplanned admission to ICU and IPD post implementation of SSC.
OT staff responded positively that number if display monitor increased, SSC had
helped in identifying pending instrument problem and it will decrease medico-
legal implications, 54.5%, 95.4% and 90% respectively.

20. RECOMMENDATIONS
• Regular and appropriate implementation of checklist is used as a tool for improving
team communication; strengthening teamwork and improving patient safety. On
top that, to amplify consistency, the active team members should be motivated to
utilize the checklist during their work practice regularly.
• Awareness generation: Awareness generation should be done for new
nursing/anesthetic staffs because of high turnover. Moreover, conducting regular
audit of checklist utilization, offering regular refreshment.
• Multidisciplinary training: Training provided to improve communication may
increase the rates of compliance with the checklist. Supplementary training and
attention to actual checklist use would be indicated to ensure that this valuable tool
could be used more routinely.
• Regular audit: Conducting regular audit of checklist utilization is also recommended
and it should be conducted on daily basis to improve compliance of SSC.
• Management should allocate the budget to meet the financial requirement for the
training of the staff and also for auditing.