Multiple interacting factors influence adherence, and outcomes associated with surgical safety checklists: a qualitative study

PLoS One. 2014 Sep 26;9(9):e108585. doi: 10.1371/journal.pone.0108585. eCollection 2014.


Objectives: The surgical safety checklist (SSC) is meant to enhance patient safety but studies of its impact conflict. This study explored factors that influenced SSC adherence to suggest how its impact could be optimized.

Methods: Participants were recruited purposively by profession, region, hospital type and time using the SSC. They were asked to describe how the SSC was adopted, associated challenges, perceived impact, and suggestions for improving its use. Grounded theory and thematic analysis were used to collect and analyse data. Findings were interpreted using an implementation fidelity conceptual framework.

Results: Fifty-one participants were interviewed (29 nurses, 13 surgeons, 9 anaesthetists; 18 small, 14 large and 19 teaching hospitals; 8 regions; 31 had used the SC for ≤12 months, 20 for 13+ months). The SSC was inconsistently reviewed, and often inaccurately documented as complete. Adherence was influenced by multiple issues. Extensive modification to accommodate existing practice patterns eliminated essential interaction at key time points to discuss patient management. Staff were often absent or not paying attention. They did not feel it was relevant to their work given limited evidence of its effectiveness, and because they were not engaged in its implementation. Organizations provided little support for implementation, training, monitoring and feedback, which are needed to overcome these, and other individual and team factors that challenged SSC adherence. Responses were similar across participants with different characteristics.

Conclusions: Multiple processes and factors influenced SSC adherence. This may explain why, in studies evaluating SSC impact, outcomes were variable. Recommendations included continuing education, time for pilot-testing, and engaging all staff in SSC review. Others may use the implementation fidelity framework to plan SSC implementation or evaluate SSC adherence. Further research is needed to establish which SSC components can be modified without compromising its effectiveness.

Publication types

  • Research Support, Non-U.S. Gov't

MeSH terms

  • Checklist*
  • Guideline Adherence*
  • Health Personnel
  • Humans
  • Patient Safety*
  • Practice Guidelines as Topic*
  • Qualitative Research
  • Safety Management*
  • Surgeons

Grants and funding

Research funding that supported this work was awarded to SES and KGS by the Canadian Health Services Research Foundation (now called Canadian Foundation for Healthcare Improvement) which took no part in study design, data collection and analysis, decision to publish, or preparation of the manuscript.