Safety culture and the 5 steps to safer surgery: an intervention study

Br J Anaesth. 2015 Jun;114(6):958-62. doi: 10.1093/bja/aev063. Epub 2015 Mar 16.


Background: Improvements in safety culture have been postulated as one of the mechanisms underlying the association between the introduction of the World Health Organisation (WHO) Surgical Safety Checklist with perioperative briefings and debriefings, and enhanced patient outcomes. The 5 Steps to Safer Surgery (5SSS) incorporates pre-list briefings, the three steps of the WHO Surgical Safety Checklist (SSC) and post-list debriefings in one framework. We aimed to identify any changes in safety culture associated with the introduction of the 5SSS in orthopaedic operating theatres.

Methods: We assessed the safety culture in the elective orthopaedic theatres of a large UK teaching hospital before and after introduction of the 5SSS using a modified version of the Safety Attitude Questionnaire - Operating Room (SAQ-OR). Primary outcome measures were pre-post intervention changes in the six safety culture domains of the SAQ-OR. We also analysed changes in responses to two items regarding perioperative briefings.

Results: The SAQ-OR survey response rate was 80% (60/75) at baseline and 74% (53/72) one yr later. There were significant improvements in both the reported frequency (P<0.001) and perceived importance (P=0.018) of briefings, and in five of the six safety culture domain scores (Working Conditions, Perceptions of Management, Job Satisfaction, Safety Climate and Teamwork Climate) of the SAQ-OR (P<0.001 in all cases). Scores in the sixth domain (Stress Recognition) decreased significantly (P=0.028).

Conclusions: Implementation of the 5SSS was associated with a significant improvement in the safety culture of elective orthopaedic operating theatres.

Keywords: checklist; safety; safety climate; safety culture; surgery.

MeSH terms

  • Attitude of Health Personnel
  • Checklist
  • Data Collection
  • Hospitals, Teaching
  • Humans
  • Job Satisfaction
  • Operating Rooms / standards
  • Organizational Culture*
  • Orthopedic Procedures / standards
  • Patient Care Team / organization & administration
  • Patient Safety / standards*
  • Perioperative Care / standards*
  • Prospective Studies
  • Quality Improvement
  • Stress, Psychological / psychology
  • Surgical Procedures, Operative / adverse effects
  • Surgical Procedures, Operative / standards*