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Simulation unmasks deficit in the knowledge of the WHO checklist among junior anaesthetists

Simulation scenario and survey

Le Guen, Morgan; Moyer, Jean-Denis; Tesnieres, Antoine; Plaud, Benoit

European Journal of Anaesthesiology (EJA): March 2016 - Volume 33 - Issue 3 - p 224–226
doi: 10.1097/EJA.0000000000000362

From the Département d’anesthésie, Hôpital Foch, Suresnes (MLG, J-DM); Département d’anesthésie-réanimation, Assistance-Publique Hôpitaux de Paris, Hôpital Cochin (AT); and Département d’anesthésie-réanimation, Assistance-Publique Hôpitaux de Paris, Hôpital Saint-Louis (BP), Paris, France

Correspondence to Morgan Le Guen, Department of Anesthesiology, University of Versailles-Saint Quentin, Hôpital Foch, 40 Rue Worth, Suresnes 92151, France Tel: +33 1 46 25 29; fax: +33 1 46 25 71 48; e-mail:

Published online 11 January 2016


Patient safety is a major concern for health authorities with regard to preventable morbidity, especially in the surgical field.1 Safety in anaesthesia has, for the most part, improved in recent years, partly due to training programs that have been introduced for laparoscopic surgery and improvement in the quality of teamwork.2,3 In this context, the implementation of a systematic and shared checklist between health professions has demonstrated a significant decrease in preventable error whatever the country.1,4,5 Therefore, the WHO recommended the Surgical Safety Checklist for every operative procedure.6 In France, the WHO checklist was introduced in 2010. The aim of the study was to explore the appropriation of this safety checklist by anaesthesia residents through high-fidelity simulation.

Junior anaesthesia residents at the end of their first year were, after having given written consent, involved in simulation-based training (Simman 3G; Laerdal, Kent, UK), whereas the other residents were observers. The workshop about the WHO checklist included two different scenarios. The first one included a risk of side of surgery error during an elective stripping of the veins in an otherwise healthy woman due to discrepancy between the anaesthesia and the medical files. The second scenario included a risk of identity error during a life-threatening transfusion. In both cases, patient interview or a shared checklist should detect the error and prevent the occurrence of a morbid event. Before the session, the students filled in a questionnaire with demographic data and questions about the WHO checklist in their daily practice. After the debriefing with all the students, a posttest questionnaire was handed out. It focused on the knowledge about the main fields (prevention of identity error, allergy, side of surgery error and so on) of the WHO checklist and the role of the present session in their future practice. Statistical analysis reported demographic characteristics and a nonparametric analysis was performed to compare the rate of correct responses before and after the session (Kruskall–Wallis). The analysis used SPSS 10.0 software (IBM, Armonk, New York, USA). and a P value lower than 0.05 was considered as statistically significant.

A total of 60 residents participated and 88% of these completed the questionnaire. Only 43% had been directly involved in the use of the Safety Surgical Checklist during their clinical training course. A total of 64% declared to have been involved in a real-life crisis situation. The rate of positive responses to the questions about the checklist was similar before and after the session (Table 1). The number of training periods (one or two) in anaesthesia did not influence the score (9.5 ± 2.1 versus 9.9 ± 2.0, P = 0.555; Fig. 1). Nevertheless, a more significant improvement was observed for residents who had spent less time in the operating theatre (Fig. 1). The role during the session did not influence performance in the correct rate of response at the end (10.0 ± 1.7 for active and 10.4 ± 1.3 for observers, P = 0.351). Side of surgery error was not detected in 25% of the sessions and was secondarily diagnosed during debriefing. In the transfusion scenario, the error of identity reached 50% with an immediate cessation of the transfusion in both cases as soon as degradation deterioration occurred. The life-threatening context was the main reason not to have a control group as one would usually do. Following the debriefing, the junior anaesthesia residents declared the ‘crossed-check’ as an important message and 80% declared that this session will change their routine practice.

Table 1

Table 1

Fig. 1

Fig. 1

This study emphasised that junior anaesthesia residents were not really involved in the whole checklist verification and have a limited knowledge of the processes in preventing medical errors. After a simulation session that proposed a high risk of error situation, they changed their minds and declared they that would change their future practice.

The poor involvement of the anaesthesia residents in completing the WHO checklist is of particular importance because it may threaten the successful implementation of a safety culture. Preventable errors are the cornerstone of the surgical safety checklist, with a special focus on the prevention of identity error, side of surgery error, allergy and antibiotic omission. A U.S. medical insurance database reported surgical errors and demonstrated 25 wrong-patient procedures and 107 wrong-site procedures.7 Most errors were due to poor communication, incorrect diagnosis or failure to implement a final set of preoperative checks. Introducing surgical checklists is not as straightforward as it seems, and requires leadership, flexibility and teamwork in a different way to that which is currently practised.8 First, it requires people to change their work routines; for example, the Time Out phase requires the entire operating theatre team to gather and pause for a few seconds before proceeding with an operation. A recent analysis has shown that it is difficult to capture the anaesthetist's attention at this time.9 Second, the components that facilitate communication are often neglected. This could be partially related to the fact that the importance of safety is closely linked to the exposure to direct risk faced by participants. It is plausible that the personnel's conception of risk and the perceived importance of different checklist items are factors that influence checklist usage. This reasoning is still not widely acknowledged in medicine and this may explain why the Time-Out is not always performed as a team effort.10 Third, compliance with checklist items varies among personnel groups. Highest compliance was associated with patient identity, type of procedure and antibiotics, the worst with site of incision, theatre nurse team reviews and imaging information.11

To improve compliance and involve the whole team, the concept of risk and the perceived relevance of checklist items for all team members should be addressed. Simulation-based training involving the whole team (multidisciplinary training) provides a well tolerated way to improve the quality of reporting with a quick self-report of change in the current practice.12 In this specific situation, simulation can provide a place for contextualised learning. It amplifies real patient experiences in a fully interactive manner.13 Simulation-based training is now recognised as an effective way to improve teamwork and efficient communication as well as in detection of adverse events.14 This global favourable environment may explain why a high percentage of junior anaesthetists (80%) declared a wish to involve themselves in the safety culture of the operative room. Therefore, such training is now used in many organisations to prompt dialogue between professionals and to offer training opportunities without compromising patient safety. The WHO Surgical Safety Checklist ensures standards of care and can be incorporated into preoperative practice. It is an effective way of preventing such errors, but its adoption by healthcare professionals is variable. The surgical checklist was well perceived by residents in this study. This could promote the safety culture by junior members of the team and could reinforce implementation of the surgical safety checklist. Nevertheless, simulation has revealed a discrepancy between theoretical knowledge and practice wherein real error occurred in one-third of the sessions mainly with transfusion and identity confusion in an emergency context. This study has some limitations. First, it did not explore the real contribution of this session on junior anaesthetists’ subsequent practice. Second, the debriefing could be criticised because the improvement of knowledge before and after the session was minor.

In conclusion, this study revealed a limited use of the surgical safety checklist among junior anaesthetists. This emphasised a possible lack in basic knowledge before their clinical practice. It also pointed to a possible barrier in the implementation of this tool in the operating theatre by the whole team, which should be actively involved and cohesive in these critical steps of surgery. Multidisciplinary simulation-based training in using the surgical checklist and team communication could be a possible solution in order to improve patient safety.

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Acknowledgements relating to this article

Assistance with the letter: we would like to thank all the participants.

Financial support and sponsorship: none.

Conflicts of interests: none.

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