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WA Surgical Safety Checklist
cooling the operating room climate one ldquotickrdquo at a time
Tanya GawthorneOffice of Safety amp Quality in Healthcare
Delivering a Healthy WA
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
OutlineBackground ndash what is the problem
International amp national action
WA action
Q amp A
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
The problemhellip hellipEmma
bull Otitis media 3 yrsbull Grommet insertionbull 8 patients on list Emma 4thbull Surgeon called awaybull Senior Registrar late
consentedbull Biscuit op cancelled Emma
3rd sent downbull Operation completedbull Moved to recovery
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
The problemhellip hellipEmma
Emma mistakenly received tonsillectomy instead of grommet insertion
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
The problemhellip hellipEmma
Received tonsillectomy instead of grommet insertion
bull Surgeon scrub nurse not informed of cancellation
bull Operated on wrong patient
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
And itrsquos not just what we take outhellip
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
WA Data ndash sentinel events
bull Procedure (incl surgery) involving wrong patientbody part (resulting in death or major permanent loss of function)
bull Retained instruments or other material after surgery requiring re- operation or further surgical procedure
03 04
04 05
05 06
06 07
07 08
08 09
09 10
1 10 5 6 11 10 1
1 5 1 2 3 6 4
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
WA Data ndash contributing factors 0809
bull Procedure (inclsurgery) involving wrong patientbody partndash Formal handoverndash ldquoteam time outrdquo proceduresndash Policy and procedures to be followedndash Formal patient identification protocolsndash Resources to ensure two staff verify patient
identification
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
WA Data ndash contributing factors 0809
bull Retained instruments or other material after surgery requiring re-operation or further surgical procedurendash Faulty equipmentndash Need for compliance with policy and proceduresndash Need for improved written and verbal information
during handoverndash Staff fatiguendash Experience of clinical staff involved
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Global challengehellip
bull 234 million major operations per year
bull 7 million people suffer complications per year
bull 1 million people die duringafter surgery per year
bull Developed worldndash 50 hospital harmful events surgical care amp services
ndash 50 of these (25 overall) preventable if standards of care are followed and safety tools used
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Safer Surgery Saving Livesbull 2008 ndash WHO Surgical Safety Checklist
developed
bull International trial indicated significant reduction in mortality and complication rates 1
bull Checklist adopted by health services across the world
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Safer Surgery Saving Livesbull 2008 ndash WHO Surgical Safety Checklist
developed
bull International trial indicated significant reduction in mortality and complication rates 1
bull Checklist adopted by health services across the world
Sir Liam Donaldson UK National Patient Safety Agency ldquoHospitals not using a surgical safety checklist are endangering patient safety If I were to need an operation I would want to be treated somewhere using a surgical checklistrdquo
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
CHECKLISTS ndash value and utilitybull Recognised safety mechanism bull Reduce risk of error by introducing redundancies into
processes bull Used across a range of industries including health
care where complex sequencing and communication are required 2 3
bull Can expedite patient flow through busy surgical wards and generate financial savings for hospitals 4
bull improve perceptions of teamwork and safety culture among clinicians which has been empirically linked to improved patient outcomes 5
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
WHO Checklistbull Designed for universal flow of proceduresbull Arranged into three phases SIGN IN ndash TIME
OUT ndash SIGN OUTbull Ensures correct patient site and sidebull Addresses other potential errors bull Minimises complications of surgerybull Ensures best possible post-procedure patient
care
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Surgical Safety - Australian Response
2004 AHMC endorses the 5-step C3 Protocol
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
3 C Protocols
bull Developed by ACSQHC for other disciplinesndash General Radiologyndash Ultrasoundndash CT amp MRIndash Interventional Radiologyndash Nuclear Medicinendash Oral Surgeryndash Simulation Radiation Therapyndash Treatment Radiation Therapy
bull Four stage process
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
3 C Protocols conthellip
bull Four stage process1 Validation2 Matching3 Time out4 Post procedure
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Surgical Safety - Australian Response2004 AHMC endorses the 5-step C3 Protocol
2005 WA Correct PPS Policy 1st Ed
2006 Revised WA Correct PPS Policy
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Correct PPS Policy
Five Step Process1 Ensure that valid consent is
obtained2 Confirm the patientrsquos identity3 Mark the site of the surgery or
invasive procedure4 Take a final lsquoteam time outrsquo in the
operating theatre treatment or examination area
5 Ensure the correct and appropriate documents and diagnostic images are available
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Correct PPS Policy conthellip
bull Three stage process
1 Days to hours before procedure
2 Just before entering the operating theatre or treatment room
3 Immediately prior to the procedure
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Surgical Safety - Australian Response2004 AHMC endorses the 5-step C3 Protocol
2005 WA Correct PPS Policy 1st Ed
2006 Revised WA Correct PPS Policy
2008 National Compliance Audit C3 Protocolndash Variance amp deficits identified
2009 Local Compliance Audit (WA)ndash Variance amp deficits identified
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Correct PPS WA Audit Resultsbull Six hospital sites audited Oct 08 ndash Feb 09bull Considerable variance in compliance
ndash Obtaining valid consent (esp prior to administration of pre-surgery medication)
ndash Marking the surgical sitendash Final Team Time Out (esp verification of site marking
participation of anaesthetists)ndash Verification of documents amp diagnostic images
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Correct PPS WA Audit Resultsbull Six hospital sites audited Oct 08 ndash Feb 09bull Considerable variance in compliance
ndash Obtaining valid consent (esp prior to administration of pre-surgery medication)
ndash Marking the surgical sitendash Final Team Time Out (esp verification of site marking
participation of anaesthetists)ndash Verification of documents amp diagnostic images
RecommendationUpdate Correct PPS policy facilitate
implementation WHO Checklist
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Australian Response (cont)Nov 2009
ndash AHMC endorses the WHO Surgical Safety Checklist (Checklist) as agreed national strategy for surgical safety
ndash All jurisdictions to have implemented locally adapted versions by July 2011
Nov 2009ndash WA MDF endorses Checklist recommending that it be
implemented as minimum standard across WA Health
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
WHO Checklist Endorsementbull Royal Australasian College of Surgeonsbull Australian and New Zealand College of Anaesthetistsbull Royal Australian and New Zealand College of
Obstetricians and Gynaecologistsbull Royal Australian and New Zealand College of
Ophthalmologistsbull Australian College of Operating Room Nursesbull WA Medical Directorsrsquo Forum
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
WA Health Surgical Safety Checklistbull Developed throughout 2010 bull Extensive stakeholder consultation and strong
agreement consensusbull Contains ALL components of C3 Protocolbull Modest changes and adaptation to WA contextbull Rolled out in November 2010bull Operational Directive OD 031611 March 2011
httpwwwhealthwagovaucircularsnewcircularcfmCirc_ID=12773
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Adapted From
WHO SSC Implementation Manual (2009)
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
WA Health Surgical Safety Checklist (cont)
bull Minimum standardbull Sites health services can ADD elements and
move elements between phasesbull 3-phase structure must be preservedbull Signature verification that all elements have
been verbally confirmed
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
WHO Checklist Adaptation Principles
bull Each section Focusedconcisebull Each section Brief (one min per section)bull Each item Actionablebull Designed for Verbal usebull Collaborative method of adaptionbull Tested in real situations before endorsementbull Integrated into routine processes
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Next StepshellipOSQH
bull Revise WA Correct PPS Policyndash Policy framework for the WA Checklist
bull Continued liaison w ACSQHC re checklists for other specialties
bull Evaluation of WA Checklist 2012ndash Auditndash Surveysndash Other data sources (AIMS HDMS)
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Next Stepshellipyou
bull Understand Checklist amp evidence bull Identify key people
ndash SampQndash Surgical nursing leads
bull Get involvedndash Auditndash Adaptndash Participation
bull Introduce
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Contact
For further information or feedback contact
Tel (08) 9222 4080 Fax (08) 9222 4324 E-mail safetyandqualityhealthwagovauWeb httpwwwsafetyandqualityhealthwagovau
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
References1 Haynes B et al A surgical safety checklist to reduce morbidity and mortality in a
global population New England Journal of Medicine 2009 360 491-92 Gawande A The Checklist Manifesto ndash How to get things right 2009
MacMillan Press3 Hales BM Pronovost PJ The checklist--a tool for error management and
performance improvement Journal of Critical Care 2006 21(3)231-54 Semel ME Resch S Haynes AB Funk LM Bader A Berry WR Weiser TG
Gawande AA Adopting a surgical safety checklist could save money and improve the quality of care in US hospitals Health Affairs 2010 29(9)1593-9
5 Haynes B et al Changes in safety attitude and relationships to decreased postoperative morbidity and mortality following implementation of a checklist- based surgical safety intervention BMJ Qual Safety 2011 20102-7
6 httpwwwwhointpatientsafetysafesurgerytools_resourcesenindexhtml
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
OutlineBackground ndash what is the problem
International amp national action
WA action
Q amp A
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
The problemhellip hellipEmma
bull Otitis media 3 yrsbull Grommet insertionbull 8 patients on list Emma 4thbull Surgeon called awaybull Senior Registrar late
consentedbull Biscuit op cancelled Emma
3rd sent downbull Operation completedbull Moved to recovery
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
The problemhellip hellipEmma
Emma mistakenly received tonsillectomy instead of grommet insertion
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
The problemhellip hellipEmma
Received tonsillectomy instead of grommet insertion
bull Surgeon scrub nurse not informed of cancellation
bull Operated on wrong patient
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
And itrsquos not just what we take outhellip
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
WA Data ndash sentinel events
bull Procedure (incl surgery) involving wrong patientbody part (resulting in death or major permanent loss of function)
bull Retained instruments or other material after surgery requiring re- operation or further surgical procedure
03 04
04 05
05 06
06 07
07 08
08 09
09 10
1 10 5 6 11 10 1
1 5 1 2 3 6 4
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
WA Data ndash contributing factors 0809
bull Procedure (inclsurgery) involving wrong patientbody partndash Formal handoverndash ldquoteam time outrdquo proceduresndash Policy and procedures to be followedndash Formal patient identification protocolsndash Resources to ensure two staff verify patient
identification
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
WA Data ndash contributing factors 0809
bull Retained instruments or other material after surgery requiring re-operation or further surgical procedurendash Faulty equipmentndash Need for compliance with policy and proceduresndash Need for improved written and verbal information
during handoverndash Staff fatiguendash Experience of clinical staff involved
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Global challengehellip
bull 234 million major operations per year
bull 7 million people suffer complications per year
bull 1 million people die duringafter surgery per year
bull Developed worldndash 50 hospital harmful events surgical care amp services
ndash 50 of these (25 overall) preventable if standards of care are followed and safety tools used
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Safer Surgery Saving Livesbull 2008 ndash WHO Surgical Safety Checklist
developed
bull International trial indicated significant reduction in mortality and complication rates 1
bull Checklist adopted by health services across the world
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Safer Surgery Saving Livesbull 2008 ndash WHO Surgical Safety Checklist
developed
bull International trial indicated significant reduction in mortality and complication rates 1
bull Checklist adopted by health services across the world
Sir Liam Donaldson UK National Patient Safety Agency ldquoHospitals not using a surgical safety checklist are endangering patient safety If I were to need an operation I would want to be treated somewhere using a surgical checklistrdquo
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
CHECKLISTS ndash value and utilitybull Recognised safety mechanism bull Reduce risk of error by introducing redundancies into
processes bull Used across a range of industries including health
care where complex sequencing and communication are required 2 3
bull Can expedite patient flow through busy surgical wards and generate financial savings for hospitals 4
bull improve perceptions of teamwork and safety culture among clinicians which has been empirically linked to improved patient outcomes 5
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
WHO Checklistbull Designed for universal flow of proceduresbull Arranged into three phases SIGN IN ndash TIME
OUT ndash SIGN OUTbull Ensures correct patient site and sidebull Addresses other potential errors bull Minimises complications of surgerybull Ensures best possible post-procedure patient
care
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Surgical Safety - Australian Response
2004 AHMC endorses the 5-step C3 Protocol
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
3 C Protocols
bull Developed by ACSQHC for other disciplinesndash General Radiologyndash Ultrasoundndash CT amp MRIndash Interventional Radiologyndash Nuclear Medicinendash Oral Surgeryndash Simulation Radiation Therapyndash Treatment Radiation Therapy
bull Four stage process
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
3 C Protocols conthellip
bull Four stage process1 Validation2 Matching3 Time out4 Post procedure
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Surgical Safety - Australian Response2004 AHMC endorses the 5-step C3 Protocol
2005 WA Correct PPS Policy 1st Ed
2006 Revised WA Correct PPS Policy
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Correct PPS Policy
Five Step Process1 Ensure that valid consent is
obtained2 Confirm the patientrsquos identity3 Mark the site of the surgery or
invasive procedure4 Take a final lsquoteam time outrsquo in the
operating theatre treatment or examination area
5 Ensure the correct and appropriate documents and diagnostic images are available
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Correct PPS Policy conthellip
bull Three stage process
1 Days to hours before procedure
2 Just before entering the operating theatre or treatment room
3 Immediately prior to the procedure
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Surgical Safety - Australian Response2004 AHMC endorses the 5-step C3 Protocol
2005 WA Correct PPS Policy 1st Ed
2006 Revised WA Correct PPS Policy
2008 National Compliance Audit C3 Protocolndash Variance amp deficits identified
2009 Local Compliance Audit (WA)ndash Variance amp deficits identified
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Correct PPS WA Audit Resultsbull Six hospital sites audited Oct 08 ndash Feb 09bull Considerable variance in compliance
ndash Obtaining valid consent (esp prior to administration of pre-surgery medication)
ndash Marking the surgical sitendash Final Team Time Out (esp verification of site marking
participation of anaesthetists)ndash Verification of documents amp diagnostic images
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Correct PPS WA Audit Resultsbull Six hospital sites audited Oct 08 ndash Feb 09bull Considerable variance in compliance
ndash Obtaining valid consent (esp prior to administration of pre-surgery medication)
ndash Marking the surgical sitendash Final Team Time Out (esp verification of site marking
participation of anaesthetists)ndash Verification of documents amp diagnostic images
RecommendationUpdate Correct PPS policy facilitate
implementation WHO Checklist
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Australian Response (cont)Nov 2009
ndash AHMC endorses the WHO Surgical Safety Checklist (Checklist) as agreed national strategy for surgical safety
ndash All jurisdictions to have implemented locally adapted versions by July 2011
Nov 2009ndash WA MDF endorses Checklist recommending that it be
implemented as minimum standard across WA Health
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
WHO Checklist Endorsementbull Royal Australasian College of Surgeonsbull Australian and New Zealand College of Anaesthetistsbull Royal Australian and New Zealand College of
Obstetricians and Gynaecologistsbull Royal Australian and New Zealand College of
Ophthalmologistsbull Australian College of Operating Room Nursesbull WA Medical Directorsrsquo Forum
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
WA Health Surgical Safety Checklistbull Developed throughout 2010 bull Extensive stakeholder consultation and strong
agreement consensusbull Contains ALL components of C3 Protocolbull Modest changes and adaptation to WA contextbull Rolled out in November 2010bull Operational Directive OD 031611 March 2011
httpwwwhealthwagovaucircularsnewcircularcfmCirc_ID=12773
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Adapted From
WHO SSC Implementation Manual (2009)
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
WA Health Surgical Safety Checklist (cont)
bull Minimum standardbull Sites health services can ADD elements and
move elements between phasesbull 3-phase structure must be preservedbull Signature verification that all elements have
been verbally confirmed
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
WHO Checklist Adaptation Principles
bull Each section Focusedconcisebull Each section Brief (one min per section)bull Each item Actionablebull Designed for Verbal usebull Collaborative method of adaptionbull Tested in real situations before endorsementbull Integrated into routine processes
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Next StepshellipOSQH
bull Revise WA Correct PPS Policyndash Policy framework for the WA Checklist
bull Continued liaison w ACSQHC re checklists for other specialties
bull Evaluation of WA Checklist 2012ndash Auditndash Surveysndash Other data sources (AIMS HDMS)
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Next Stepshellipyou
bull Understand Checklist amp evidence bull Identify key people
ndash SampQndash Surgical nursing leads
bull Get involvedndash Auditndash Adaptndash Participation
bull Introduce
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Contact
For further information or feedback contact
Tel (08) 9222 4080 Fax (08) 9222 4324 E-mail safetyandqualityhealthwagovauWeb httpwwwsafetyandqualityhealthwagovau
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
References1 Haynes B et al A surgical safety checklist to reduce morbidity and mortality in a
global population New England Journal of Medicine 2009 360 491-92 Gawande A The Checklist Manifesto ndash How to get things right 2009
MacMillan Press3 Hales BM Pronovost PJ The checklist--a tool for error management and
performance improvement Journal of Critical Care 2006 21(3)231-54 Semel ME Resch S Haynes AB Funk LM Bader A Berry WR Weiser TG
Gawande AA Adopting a surgical safety checklist could save money and improve the quality of care in US hospitals Health Affairs 2010 29(9)1593-9
5 Haynes B et al Changes in safety attitude and relationships to decreased postoperative morbidity and mortality following implementation of a checklist- based surgical safety intervention BMJ Qual Safety 2011 20102-7
6 httpwwwwhointpatientsafetysafesurgerytools_resourcesenindexhtml
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
The problemhellip hellipEmma
bull Otitis media 3 yrsbull Grommet insertionbull 8 patients on list Emma 4thbull Surgeon called awaybull Senior Registrar late
consentedbull Biscuit op cancelled Emma
3rd sent downbull Operation completedbull Moved to recovery
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
The problemhellip hellipEmma
Emma mistakenly received tonsillectomy instead of grommet insertion
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
The problemhellip hellipEmma
Received tonsillectomy instead of grommet insertion
bull Surgeon scrub nurse not informed of cancellation
bull Operated on wrong patient
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
And itrsquos not just what we take outhellip
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
WA Data ndash sentinel events
bull Procedure (incl surgery) involving wrong patientbody part (resulting in death or major permanent loss of function)
bull Retained instruments or other material after surgery requiring re- operation or further surgical procedure
03 04
04 05
05 06
06 07
07 08
08 09
09 10
1 10 5 6 11 10 1
1 5 1 2 3 6 4
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
WA Data ndash contributing factors 0809
bull Procedure (inclsurgery) involving wrong patientbody partndash Formal handoverndash ldquoteam time outrdquo proceduresndash Policy and procedures to be followedndash Formal patient identification protocolsndash Resources to ensure two staff verify patient
identification
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
WA Data ndash contributing factors 0809
bull Retained instruments or other material after surgery requiring re-operation or further surgical procedurendash Faulty equipmentndash Need for compliance with policy and proceduresndash Need for improved written and verbal information
during handoverndash Staff fatiguendash Experience of clinical staff involved
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Global challengehellip
bull 234 million major operations per year
bull 7 million people suffer complications per year
bull 1 million people die duringafter surgery per year
bull Developed worldndash 50 hospital harmful events surgical care amp services
ndash 50 of these (25 overall) preventable if standards of care are followed and safety tools used
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Safer Surgery Saving Livesbull 2008 ndash WHO Surgical Safety Checklist
developed
bull International trial indicated significant reduction in mortality and complication rates 1
bull Checklist adopted by health services across the world
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Safer Surgery Saving Livesbull 2008 ndash WHO Surgical Safety Checklist
developed
bull International trial indicated significant reduction in mortality and complication rates 1
bull Checklist adopted by health services across the world
Sir Liam Donaldson UK National Patient Safety Agency ldquoHospitals not using a surgical safety checklist are endangering patient safety If I were to need an operation I would want to be treated somewhere using a surgical checklistrdquo
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
CHECKLISTS ndash value and utilitybull Recognised safety mechanism bull Reduce risk of error by introducing redundancies into
processes bull Used across a range of industries including health
care where complex sequencing and communication are required 2 3
bull Can expedite patient flow through busy surgical wards and generate financial savings for hospitals 4
bull improve perceptions of teamwork and safety culture among clinicians which has been empirically linked to improved patient outcomes 5
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
WHO Checklistbull Designed for universal flow of proceduresbull Arranged into three phases SIGN IN ndash TIME
OUT ndash SIGN OUTbull Ensures correct patient site and sidebull Addresses other potential errors bull Minimises complications of surgerybull Ensures best possible post-procedure patient
care
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Surgical Safety - Australian Response
2004 AHMC endorses the 5-step C3 Protocol
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
3 C Protocols
bull Developed by ACSQHC for other disciplinesndash General Radiologyndash Ultrasoundndash CT amp MRIndash Interventional Radiologyndash Nuclear Medicinendash Oral Surgeryndash Simulation Radiation Therapyndash Treatment Radiation Therapy
bull Four stage process
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
3 C Protocols conthellip
bull Four stage process1 Validation2 Matching3 Time out4 Post procedure
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Surgical Safety - Australian Response2004 AHMC endorses the 5-step C3 Protocol
2005 WA Correct PPS Policy 1st Ed
2006 Revised WA Correct PPS Policy
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Correct PPS Policy
Five Step Process1 Ensure that valid consent is
obtained2 Confirm the patientrsquos identity3 Mark the site of the surgery or
invasive procedure4 Take a final lsquoteam time outrsquo in the
operating theatre treatment or examination area
5 Ensure the correct and appropriate documents and diagnostic images are available
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Correct PPS Policy conthellip
bull Three stage process
1 Days to hours before procedure
2 Just before entering the operating theatre or treatment room
3 Immediately prior to the procedure
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Surgical Safety - Australian Response2004 AHMC endorses the 5-step C3 Protocol
2005 WA Correct PPS Policy 1st Ed
2006 Revised WA Correct PPS Policy
2008 National Compliance Audit C3 Protocolndash Variance amp deficits identified
2009 Local Compliance Audit (WA)ndash Variance amp deficits identified
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Correct PPS WA Audit Resultsbull Six hospital sites audited Oct 08 ndash Feb 09bull Considerable variance in compliance
ndash Obtaining valid consent (esp prior to administration of pre-surgery medication)
ndash Marking the surgical sitendash Final Team Time Out (esp verification of site marking
participation of anaesthetists)ndash Verification of documents amp diagnostic images
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Correct PPS WA Audit Resultsbull Six hospital sites audited Oct 08 ndash Feb 09bull Considerable variance in compliance
ndash Obtaining valid consent (esp prior to administration of pre-surgery medication)
ndash Marking the surgical sitendash Final Team Time Out (esp verification of site marking
participation of anaesthetists)ndash Verification of documents amp diagnostic images
RecommendationUpdate Correct PPS policy facilitate
implementation WHO Checklist
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Australian Response (cont)Nov 2009
ndash AHMC endorses the WHO Surgical Safety Checklist (Checklist) as agreed national strategy for surgical safety
ndash All jurisdictions to have implemented locally adapted versions by July 2011
Nov 2009ndash WA MDF endorses Checklist recommending that it be
implemented as minimum standard across WA Health
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
WHO Checklist Endorsementbull Royal Australasian College of Surgeonsbull Australian and New Zealand College of Anaesthetistsbull Royal Australian and New Zealand College of
Obstetricians and Gynaecologistsbull Royal Australian and New Zealand College of
Ophthalmologistsbull Australian College of Operating Room Nursesbull WA Medical Directorsrsquo Forum
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
WA Health Surgical Safety Checklistbull Developed throughout 2010 bull Extensive stakeholder consultation and strong
agreement consensusbull Contains ALL components of C3 Protocolbull Modest changes and adaptation to WA contextbull Rolled out in November 2010bull Operational Directive OD 031611 March 2011
httpwwwhealthwagovaucircularsnewcircularcfmCirc_ID=12773
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Adapted From
WHO SSC Implementation Manual (2009)
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
WA Health Surgical Safety Checklist (cont)
bull Minimum standardbull Sites health services can ADD elements and
move elements between phasesbull 3-phase structure must be preservedbull Signature verification that all elements have
been verbally confirmed
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
WHO Checklist Adaptation Principles
bull Each section Focusedconcisebull Each section Brief (one min per section)bull Each item Actionablebull Designed for Verbal usebull Collaborative method of adaptionbull Tested in real situations before endorsementbull Integrated into routine processes
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Next StepshellipOSQH
bull Revise WA Correct PPS Policyndash Policy framework for the WA Checklist
bull Continued liaison w ACSQHC re checklists for other specialties
bull Evaluation of WA Checklist 2012ndash Auditndash Surveysndash Other data sources (AIMS HDMS)
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Next Stepshellipyou
bull Understand Checklist amp evidence bull Identify key people
ndash SampQndash Surgical nursing leads
bull Get involvedndash Auditndash Adaptndash Participation
bull Introduce
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Contact
For further information or feedback contact
Tel (08) 9222 4080 Fax (08) 9222 4324 E-mail safetyandqualityhealthwagovauWeb httpwwwsafetyandqualityhealthwagovau
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
References1 Haynes B et al A surgical safety checklist to reduce morbidity and mortality in a
global population New England Journal of Medicine 2009 360 491-92 Gawande A The Checklist Manifesto ndash How to get things right 2009
MacMillan Press3 Hales BM Pronovost PJ The checklist--a tool for error management and
performance improvement Journal of Critical Care 2006 21(3)231-54 Semel ME Resch S Haynes AB Funk LM Bader A Berry WR Weiser TG
Gawande AA Adopting a surgical safety checklist could save money and improve the quality of care in US hospitals Health Affairs 2010 29(9)1593-9
5 Haynes B et al Changes in safety attitude and relationships to decreased postoperative morbidity and mortality following implementation of a checklist- based surgical safety intervention BMJ Qual Safety 2011 20102-7
6 httpwwwwhointpatientsafetysafesurgerytools_resourcesenindexhtml
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
The problemhellip hellipEmma
Emma mistakenly received tonsillectomy instead of grommet insertion
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
The problemhellip hellipEmma
Received tonsillectomy instead of grommet insertion
bull Surgeon scrub nurse not informed of cancellation
bull Operated on wrong patient
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
And itrsquos not just what we take outhellip
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
WA Data ndash sentinel events
bull Procedure (incl surgery) involving wrong patientbody part (resulting in death or major permanent loss of function)
bull Retained instruments or other material after surgery requiring re- operation or further surgical procedure
03 04
04 05
05 06
06 07
07 08
08 09
09 10
1 10 5 6 11 10 1
1 5 1 2 3 6 4
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
WA Data ndash contributing factors 0809
bull Procedure (inclsurgery) involving wrong patientbody partndash Formal handoverndash ldquoteam time outrdquo proceduresndash Policy and procedures to be followedndash Formal patient identification protocolsndash Resources to ensure two staff verify patient
identification
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
WA Data ndash contributing factors 0809
bull Retained instruments or other material after surgery requiring re-operation or further surgical procedurendash Faulty equipmentndash Need for compliance with policy and proceduresndash Need for improved written and verbal information
during handoverndash Staff fatiguendash Experience of clinical staff involved
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Global challengehellip
bull 234 million major operations per year
bull 7 million people suffer complications per year
bull 1 million people die duringafter surgery per year
bull Developed worldndash 50 hospital harmful events surgical care amp services
ndash 50 of these (25 overall) preventable if standards of care are followed and safety tools used
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Safer Surgery Saving Livesbull 2008 ndash WHO Surgical Safety Checklist
developed
bull International trial indicated significant reduction in mortality and complication rates 1
bull Checklist adopted by health services across the world
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Safer Surgery Saving Livesbull 2008 ndash WHO Surgical Safety Checklist
developed
bull International trial indicated significant reduction in mortality and complication rates 1
bull Checklist adopted by health services across the world
Sir Liam Donaldson UK National Patient Safety Agency ldquoHospitals not using a surgical safety checklist are endangering patient safety If I were to need an operation I would want to be treated somewhere using a surgical checklistrdquo
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
CHECKLISTS ndash value and utilitybull Recognised safety mechanism bull Reduce risk of error by introducing redundancies into
processes bull Used across a range of industries including health
care where complex sequencing and communication are required 2 3
bull Can expedite patient flow through busy surgical wards and generate financial savings for hospitals 4
bull improve perceptions of teamwork and safety culture among clinicians which has been empirically linked to improved patient outcomes 5
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
WHO Checklistbull Designed for universal flow of proceduresbull Arranged into three phases SIGN IN ndash TIME
OUT ndash SIGN OUTbull Ensures correct patient site and sidebull Addresses other potential errors bull Minimises complications of surgerybull Ensures best possible post-procedure patient
care
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Surgical Safety - Australian Response
2004 AHMC endorses the 5-step C3 Protocol
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
3 C Protocols
bull Developed by ACSQHC for other disciplinesndash General Radiologyndash Ultrasoundndash CT amp MRIndash Interventional Radiologyndash Nuclear Medicinendash Oral Surgeryndash Simulation Radiation Therapyndash Treatment Radiation Therapy
bull Four stage process
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
3 C Protocols conthellip
bull Four stage process1 Validation2 Matching3 Time out4 Post procedure
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Surgical Safety - Australian Response2004 AHMC endorses the 5-step C3 Protocol
2005 WA Correct PPS Policy 1st Ed
2006 Revised WA Correct PPS Policy
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Correct PPS Policy
Five Step Process1 Ensure that valid consent is
obtained2 Confirm the patientrsquos identity3 Mark the site of the surgery or
invasive procedure4 Take a final lsquoteam time outrsquo in the
operating theatre treatment or examination area
5 Ensure the correct and appropriate documents and diagnostic images are available
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Correct PPS Policy conthellip
bull Three stage process
1 Days to hours before procedure
2 Just before entering the operating theatre or treatment room
3 Immediately prior to the procedure
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Surgical Safety - Australian Response2004 AHMC endorses the 5-step C3 Protocol
2005 WA Correct PPS Policy 1st Ed
2006 Revised WA Correct PPS Policy
2008 National Compliance Audit C3 Protocolndash Variance amp deficits identified
2009 Local Compliance Audit (WA)ndash Variance amp deficits identified
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Correct PPS WA Audit Resultsbull Six hospital sites audited Oct 08 ndash Feb 09bull Considerable variance in compliance
ndash Obtaining valid consent (esp prior to administration of pre-surgery medication)
ndash Marking the surgical sitendash Final Team Time Out (esp verification of site marking
participation of anaesthetists)ndash Verification of documents amp diagnostic images
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Correct PPS WA Audit Resultsbull Six hospital sites audited Oct 08 ndash Feb 09bull Considerable variance in compliance
ndash Obtaining valid consent (esp prior to administration of pre-surgery medication)
ndash Marking the surgical sitendash Final Team Time Out (esp verification of site marking
participation of anaesthetists)ndash Verification of documents amp diagnostic images
RecommendationUpdate Correct PPS policy facilitate
implementation WHO Checklist
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Australian Response (cont)Nov 2009
ndash AHMC endorses the WHO Surgical Safety Checklist (Checklist) as agreed national strategy for surgical safety
ndash All jurisdictions to have implemented locally adapted versions by July 2011
Nov 2009ndash WA MDF endorses Checklist recommending that it be
implemented as minimum standard across WA Health
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
WHO Checklist Endorsementbull Royal Australasian College of Surgeonsbull Australian and New Zealand College of Anaesthetistsbull Royal Australian and New Zealand College of
Obstetricians and Gynaecologistsbull Royal Australian and New Zealand College of
Ophthalmologistsbull Australian College of Operating Room Nursesbull WA Medical Directorsrsquo Forum
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
WA Health Surgical Safety Checklistbull Developed throughout 2010 bull Extensive stakeholder consultation and strong
agreement consensusbull Contains ALL components of C3 Protocolbull Modest changes and adaptation to WA contextbull Rolled out in November 2010bull Operational Directive OD 031611 March 2011
httpwwwhealthwagovaucircularsnewcircularcfmCirc_ID=12773
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Adapted From
WHO SSC Implementation Manual (2009)
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
WA Health Surgical Safety Checklist (cont)
bull Minimum standardbull Sites health services can ADD elements and
move elements between phasesbull 3-phase structure must be preservedbull Signature verification that all elements have
been verbally confirmed
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
WHO Checklist Adaptation Principles
bull Each section Focusedconcisebull Each section Brief (one min per section)bull Each item Actionablebull Designed for Verbal usebull Collaborative method of adaptionbull Tested in real situations before endorsementbull Integrated into routine processes
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Next StepshellipOSQH
bull Revise WA Correct PPS Policyndash Policy framework for the WA Checklist
bull Continued liaison w ACSQHC re checklists for other specialties
bull Evaluation of WA Checklist 2012ndash Auditndash Surveysndash Other data sources (AIMS HDMS)
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Next Stepshellipyou
bull Understand Checklist amp evidence bull Identify key people
ndash SampQndash Surgical nursing leads
bull Get involvedndash Auditndash Adaptndash Participation
bull Introduce
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Contact
For further information or feedback contact
Tel (08) 9222 4080 Fax (08) 9222 4324 E-mail safetyandqualityhealthwagovauWeb httpwwwsafetyandqualityhealthwagovau
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
References1 Haynes B et al A surgical safety checklist to reduce morbidity and mortality in a
global population New England Journal of Medicine 2009 360 491-92 Gawande A The Checklist Manifesto ndash How to get things right 2009
MacMillan Press3 Hales BM Pronovost PJ The checklist--a tool for error management and
performance improvement Journal of Critical Care 2006 21(3)231-54 Semel ME Resch S Haynes AB Funk LM Bader A Berry WR Weiser TG
Gawande AA Adopting a surgical safety checklist could save money and improve the quality of care in US hospitals Health Affairs 2010 29(9)1593-9
5 Haynes B et al Changes in safety attitude and relationships to decreased postoperative morbidity and mortality following implementation of a checklist- based surgical safety intervention BMJ Qual Safety 2011 20102-7
6 httpwwwwhointpatientsafetysafesurgerytools_resourcesenindexhtml
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
The problemhellip hellipEmma
Received tonsillectomy instead of grommet insertion
bull Surgeon scrub nurse not informed of cancellation
bull Operated on wrong patient
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
And itrsquos not just what we take outhellip
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
WA Data ndash sentinel events
bull Procedure (incl surgery) involving wrong patientbody part (resulting in death or major permanent loss of function)
bull Retained instruments or other material after surgery requiring re- operation or further surgical procedure
03 04
04 05
05 06
06 07
07 08
08 09
09 10
1 10 5 6 11 10 1
1 5 1 2 3 6 4
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
WA Data ndash contributing factors 0809
bull Procedure (inclsurgery) involving wrong patientbody partndash Formal handoverndash ldquoteam time outrdquo proceduresndash Policy and procedures to be followedndash Formal patient identification protocolsndash Resources to ensure two staff verify patient
identification
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
WA Data ndash contributing factors 0809
bull Retained instruments or other material after surgery requiring re-operation or further surgical procedurendash Faulty equipmentndash Need for compliance with policy and proceduresndash Need for improved written and verbal information
during handoverndash Staff fatiguendash Experience of clinical staff involved
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Global challengehellip
bull 234 million major operations per year
bull 7 million people suffer complications per year
bull 1 million people die duringafter surgery per year
bull Developed worldndash 50 hospital harmful events surgical care amp services
ndash 50 of these (25 overall) preventable if standards of care are followed and safety tools used
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Safer Surgery Saving Livesbull 2008 ndash WHO Surgical Safety Checklist
developed
bull International trial indicated significant reduction in mortality and complication rates 1
bull Checklist adopted by health services across the world
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Safer Surgery Saving Livesbull 2008 ndash WHO Surgical Safety Checklist
developed
bull International trial indicated significant reduction in mortality and complication rates 1
bull Checklist adopted by health services across the world
Sir Liam Donaldson UK National Patient Safety Agency ldquoHospitals not using a surgical safety checklist are endangering patient safety If I were to need an operation I would want to be treated somewhere using a surgical checklistrdquo
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
CHECKLISTS ndash value and utilitybull Recognised safety mechanism bull Reduce risk of error by introducing redundancies into
processes bull Used across a range of industries including health
care where complex sequencing and communication are required 2 3
bull Can expedite patient flow through busy surgical wards and generate financial savings for hospitals 4
bull improve perceptions of teamwork and safety culture among clinicians which has been empirically linked to improved patient outcomes 5
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
WHO Checklistbull Designed for universal flow of proceduresbull Arranged into three phases SIGN IN ndash TIME
OUT ndash SIGN OUTbull Ensures correct patient site and sidebull Addresses other potential errors bull Minimises complications of surgerybull Ensures best possible post-procedure patient
care
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Surgical Safety - Australian Response
2004 AHMC endorses the 5-step C3 Protocol
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
3 C Protocols
bull Developed by ACSQHC for other disciplinesndash General Radiologyndash Ultrasoundndash CT amp MRIndash Interventional Radiologyndash Nuclear Medicinendash Oral Surgeryndash Simulation Radiation Therapyndash Treatment Radiation Therapy
bull Four stage process
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
3 C Protocols conthellip
bull Four stage process1 Validation2 Matching3 Time out4 Post procedure
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Surgical Safety - Australian Response2004 AHMC endorses the 5-step C3 Protocol
2005 WA Correct PPS Policy 1st Ed
2006 Revised WA Correct PPS Policy
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Correct PPS Policy
Five Step Process1 Ensure that valid consent is
obtained2 Confirm the patientrsquos identity3 Mark the site of the surgery or
invasive procedure4 Take a final lsquoteam time outrsquo in the
operating theatre treatment or examination area
5 Ensure the correct and appropriate documents and diagnostic images are available
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Correct PPS Policy conthellip
bull Three stage process
1 Days to hours before procedure
2 Just before entering the operating theatre or treatment room
3 Immediately prior to the procedure
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Surgical Safety - Australian Response2004 AHMC endorses the 5-step C3 Protocol
2005 WA Correct PPS Policy 1st Ed
2006 Revised WA Correct PPS Policy
2008 National Compliance Audit C3 Protocolndash Variance amp deficits identified
2009 Local Compliance Audit (WA)ndash Variance amp deficits identified
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Correct PPS WA Audit Resultsbull Six hospital sites audited Oct 08 ndash Feb 09bull Considerable variance in compliance
ndash Obtaining valid consent (esp prior to administration of pre-surgery medication)
ndash Marking the surgical sitendash Final Team Time Out (esp verification of site marking
participation of anaesthetists)ndash Verification of documents amp diagnostic images
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Correct PPS WA Audit Resultsbull Six hospital sites audited Oct 08 ndash Feb 09bull Considerable variance in compliance
ndash Obtaining valid consent (esp prior to administration of pre-surgery medication)
ndash Marking the surgical sitendash Final Team Time Out (esp verification of site marking
participation of anaesthetists)ndash Verification of documents amp diagnostic images
RecommendationUpdate Correct PPS policy facilitate
implementation WHO Checklist
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Australian Response (cont)Nov 2009
ndash AHMC endorses the WHO Surgical Safety Checklist (Checklist) as agreed national strategy for surgical safety
ndash All jurisdictions to have implemented locally adapted versions by July 2011
Nov 2009ndash WA MDF endorses Checklist recommending that it be
implemented as minimum standard across WA Health
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
WHO Checklist Endorsementbull Royal Australasian College of Surgeonsbull Australian and New Zealand College of Anaesthetistsbull Royal Australian and New Zealand College of
Obstetricians and Gynaecologistsbull Royal Australian and New Zealand College of
Ophthalmologistsbull Australian College of Operating Room Nursesbull WA Medical Directorsrsquo Forum
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
WA Health Surgical Safety Checklistbull Developed throughout 2010 bull Extensive stakeholder consultation and strong
agreement consensusbull Contains ALL components of C3 Protocolbull Modest changes and adaptation to WA contextbull Rolled out in November 2010bull Operational Directive OD 031611 March 2011
httpwwwhealthwagovaucircularsnewcircularcfmCirc_ID=12773
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Adapted From
WHO SSC Implementation Manual (2009)
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
WA Health Surgical Safety Checklist (cont)
bull Minimum standardbull Sites health services can ADD elements and
move elements between phasesbull 3-phase structure must be preservedbull Signature verification that all elements have
been verbally confirmed
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
WHO Checklist Adaptation Principles
bull Each section Focusedconcisebull Each section Brief (one min per section)bull Each item Actionablebull Designed for Verbal usebull Collaborative method of adaptionbull Tested in real situations before endorsementbull Integrated into routine processes
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Next StepshellipOSQH
bull Revise WA Correct PPS Policyndash Policy framework for the WA Checklist
bull Continued liaison w ACSQHC re checklists for other specialties
bull Evaluation of WA Checklist 2012ndash Auditndash Surveysndash Other data sources (AIMS HDMS)
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Next Stepshellipyou
bull Understand Checklist amp evidence bull Identify key people
ndash SampQndash Surgical nursing leads
bull Get involvedndash Auditndash Adaptndash Participation
bull Introduce
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Contact
For further information or feedback contact
Tel (08) 9222 4080 Fax (08) 9222 4324 E-mail safetyandqualityhealthwagovauWeb httpwwwsafetyandqualityhealthwagovau
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
References1 Haynes B et al A surgical safety checklist to reduce morbidity and mortality in a
global population New England Journal of Medicine 2009 360 491-92 Gawande A The Checklist Manifesto ndash How to get things right 2009
MacMillan Press3 Hales BM Pronovost PJ The checklist--a tool for error management and
performance improvement Journal of Critical Care 2006 21(3)231-54 Semel ME Resch S Haynes AB Funk LM Bader A Berry WR Weiser TG
Gawande AA Adopting a surgical safety checklist could save money and improve the quality of care in US hospitals Health Affairs 2010 29(9)1593-9
5 Haynes B et al Changes in safety attitude and relationships to decreased postoperative morbidity and mortality following implementation of a checklist- based surgical safety intervention BMJ Qual Safety 2011 20102-7
6 httpwwwwhointpatientsafetysafesurgerytools_resourcesenindexhtml
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
And itrsquos not just what we take outhellip
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
WA Data ndash sentinel events
bull Procedure (incl surgery) involving wrong patientbody part (resulting in death or major permanent loss of function)
bull Retained instruments or other material after surgery requiring re- operation or further surgical procedure
03 04
04 05
05 06
06 07
07 08
08 09
09 10
1 10 5 6 11 10 1
1 5 1 2 3 6 4
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
WA Data ndash contributing factors 0809
bull Procedure (inclsurgery) involving wrong patientbody partndash Formal handoverndash ldquoteam time outrdquo proceduresndash Policy and procedures to be followedndash Formal patient identification protocolsndash Resources to ensure two staff verify patient
identification
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
WA Data ndash contributing factors 0809
bull Retained instruments or other material after surgery requiring re-operation or further surgical procedurendash Faulty equipmentndash Need for compliance with policy and proceduresndash Need for improved written and verbal information
during handoverndash Staff fatiguendash Experience of clinical staff involved
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Global challengehellip
bull 234 million major operations per year
bull 7 million people suffer complications per year
bull 1 million people die duringafter surgery per year
bull Developed worldndash 50 hospital harmful events surgical care amp services
ndash 50 of these (25 overall) preventable if standards of care are followed and safety tools used
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Safer Surgery Saving Livesbull 2008 ndash WHO Surgical Safety Checklist
developed
bull International trial indicated significant reduction in mortality and complication rates 1
bull Checklist adopted by health services across the world
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Safer Surgery Saving Livesbull 2008 ndash WHO Surgical Safety Checklist
developed
bull International trial indicated significant reduction in mortality and complication rates 1
bull Checklist adopted by health services across the world
Sir Liam Donaldson UK National Patient Safety Agency ldquoHospitals not using a surgical safety checklist are endangering patient safety If I were to need an operation I would want to be treated somewhere using a surgical checklistrdquo
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
CHECKLISTS ndash value and utilitybull Recognised safety mechanism bull Reduce risk of error by introducing redundancies into
processes bull Used across a range of industries including health
care where complex sequencing and communication are required 2 3
bull Can expedite patient flow through busy surgical wards and generate financial savings for hospitals 4
bull improve perceptions of teamwork and safety culture among clinicians which has been empirically linked to improved patient outcomes 5
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
WHO Checklistbull Designed for universal flow of proceduresbull Arranged into three phases SIGN IN ndash TIME
OUT ndash SIGN OUTbull Ensures correct patient site and sidebull Addresses other potential errors bull Minimises complications of surgerybull Ensures best possible post-procedure patient
care
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Surgical Safety - Australian Response
2004 AHMC endorses the 5-step C3 Protocol
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
3 C Protocols
bull Developed by ACSQHC for other disciplinesndash General Radiologyndash Ultrasoundndash CT amp MRIndash Interventional Radiologyndash Nuclear Medicinendash Oral Surgeryndash Simulation Radiation Therapyndash Treatment Radiation Therapy
bull Four stage process
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
3 C Protocols conthellip
bull Four stage process1 Validation2 Matching3 Time out4 Post procedure
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Surgical Safety - Australian Response2004 AHMC endorses the 5-step C3 Protocol
2005 WA Correct PPS Policy 1st Ed
2006 Revised WA Correct PPS Policy
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Correct PPS Policy
Five Step Process1 Ensure that valid consent is
obtained2 Confirm the patientrsquos identity3 Mark the site of the surgery or
invasive procedure4 Take a final lsquoteam time outrsquo in the
operating theatre treatment or examination area
5 Ensure the correct and appropriate documents and diagnostic images are available
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Correct PPS Policy conthellip
bull Three stage process
1 Days to hours before procedure
2 Just before entering the operating theatre or treatment room
3 Immediately prior to the procedure
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Surgical Safety - Australian Response2004 AHMC endorses the 5-step C3 Protocol
2005 WA Correct PPS Policy 1st Ed
2006 Revised WA Correct PPS Policy
2008 National Compliance Audit C3 Protocolndash Variance amp deficits identified
2009 Local Compliance Audit (WA)ndash Variance amp deficits identified
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Correct PPS WA Audit Resultsbull Six hospital sites audited Oct 08 ndash Feb 09bull Considerable variance in compliance
ndash Obtaining valid consent (esp prior to administration of pre-surgery medication)
ndash Marking the surgical sitendash Final Team Time Out (esp verification of site marking
participation of anaesthetists)ndash Verification of documents amp diagnostic images
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Correct PPS WA Audit Resultsbull Six hospital sites audited Oct 08 ndash Feb 09bull Considerable variance in compliance
ndash Obtaining valid consent (esp prior to administration of pre-surgery medication)
ndash Marking the surgical sitendash Final Team Time Out (esp verification of site marking
participation of anaesthetists)ndash Verification of documents amp diagnostic images
RecommendationUpdate Correct PPS policy facilitate
implementation WHO Checklist
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Australian Response (cont)Nov 2009
ndash AHMC endorses the WHO Surgical Safety Checklist (Checklist) as agreed national strategy for surgical safety
ndash All jurisdictions to have implemented locally adapted versions by July 2011
Nov 2009ndash WA MDF endorses Checklist recommending that it be
implemented as minimum standard across WA Health
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
WHO Checklist Endorsementbull Royal Australasian College of Surgeonsbull Australian and New Zealand College of Anaesthetistsbull Royal Australian and New Zealand College of
Obstetricians and Gynaecologistsbull Royal Australian and New Zealand College of
Ophthalmologistsbull Australian College of Operating Room Nursesbull WA Medical Directorsrsquo Forum
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
WA Health Surgical Safety Checklistbull Developed throughout 2010 bull Extensive stakeholder consultation and strong
agreement consensusbull Contains ALL components of C3 Protocolbull Modest changes and adaptation to WA contextbull Rolled out in November 2010bull Operational Directive OD 031611 March 2011
httpwwwhealthwagovaucircularsnewcircularcfmCirc_ID=12773
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Adapted From
WHO SSC Implementation Manual (2009)
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
WA Health Surgical Safety Checklist (cont)
bull Minimum standardbull Sites health services can ADD elements and
move elements between phasesbull 3-phase structure must be preservedbull Signature verification that all elements have
been verbally confirmed
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
WHO Checklist Adaptation Principles
bull Each section Focusedconcisebull Each section Brief (one min per section)bull Each item Actionablebull Designed for Verbal usebull Collaborative method of adaptionbull Tested in real situations before endorsementbull Integrated into routine processes
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Next StepshellipOSQH
bull Revise WA Correct PPS Policyndash Policy framework for the WA Checklist
bull Continued liaison w ACSQHC re checklists for other specialties
bull Evaluation of WA Checklist 2012ndash Auditndash Surveysndash Other data sources (AIMS HDMS)
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Next Stepshellipyou
bull Understand Checklist amp evidence bull Identify key people
ndash SampQndash Surgical nursing leads
bull Get involvedndash Auditndash Adaptndash Participation
bull Introduce
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Contact
For further information or feedback contact
Tel (08) 9222 4080 Fax (08) 9222 4324 E-mail safetyandqualityhealthwagovauWeb httpwwwsafetyandqualityhealthwagovau
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
References1 Haynes B et al A surgical safety checklist to reduce morbidity and mortality in a
global population New England Journal of Medicine 2009 360 491-92 Gawande A The Checklist Manifesto ndash How to get things right 2009
MacMillan Press3 Hales BM Pronovost PJ The checklist--a tool for error management and
performance improvement Journal of Critical Care 2006 21(3)231-54 Semel ME Resch S Haynes AB Funk LM Bader A Berry WR Weiser TG
Gawande AA Adopting a surgical safety checklist could save money and improve the quality of care in US hospitals Health Affairs 2010 29(9)1593-9
5 Haynes B et al Changes in safety attitude and relationships to decreased postoperative morbidity and mortality following implementation of a checklist- based surgical safety intervention BMJ Qual Safety 2011 20102-7
6 httpwwwwhointpatientsafetysafesurgerytools_resourcesenindexhtml
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
WA Data ndash sentinel events
bull Procedure (incl surgery) involving wrong patientbody part (resulting in death or major permanent loss of function)
bull Retained instruments or other material after surgery requiring re- operation or further surgical procedure
03 04
04 05
05 06
06 07
07 08
08 09
09 10
1 10 5 6 11 10 1
1 5 1 2 3 6 4
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
WA Data ndash contributing factors 0809
bull Procedure (inclsurgery) involving wrong patientbody partndash Formal handoverndash ldquoteam time outrdquo proceduresndash Policy and procedures to be followedndash Formal patient identification protocolsndash Resources to ensure two staff verify patient
identification
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
WA Data ndash contributing factors 0809
bull Retained instruments or other material after surgery requiring re-operation or further surgical procedurendash Faulty equipmentndash Need for compliance with policy and proceduresndash Need for improved written and verbal information
during handoverndash Staff fatiguendash Experience of clinical staff involved
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Global challengehellip
bull 234 million major operations per year
bull 7 million people suffer complications per year
bull 1 million people die duringafter surgery per year
bull Developed worldndash 50 hospital harmful events surgical care amp services
ndash 50 of these (25 overall) preventable if standards of care are followed and safety tools used
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Safer Surgery Saving Livesbull 2008 ndash WHO Surgical Safety Checklist
developed
bull International trial indicated significant reduction in mortality and complication rates 1
bull Checklist adopted by health services across the world
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Safer Surgery Saving Livesbull 2008 ndash WHO Surgical Safety Checklist
developed
bull International trial indicated significant reduction in mortality and complication rates 1
bull Checklist adopted by health services across the world
Sir Liam Donaldson UK National Patient Safety Agency ldquoHospitals not using a surgical safety checklist are endangering patient safety If I were to need an operation I would want to be treated somewhere using a surgical checklistrdquo
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
CHECKLISTS ndash value and utilitybull Recognised safety mechanism bull Reduce risk of error by introducing redundancies into
processes bull Used across a range of industries including health
care where complex sequencing and communication are required 2 3
bull Can expedite patient flow through busy surgical wards and generate financial savings for hospitals 4
bull improve perceptions of teamwork and safety culture among clinicians which has been empirically linked to improved patient outcomes 5
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
WHO Checklistbull Designed for universal flow of proceduresbull Arranged into three phases SIGN IN ndash TIME
OUT ndash SIGN OUTbull Ensures correct patient site and sidebull Addresses other potential errors bull Minimises complications of surgerybull Ensures best possible post-procedure patient
care
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Surgical Safety - Australian Response
2004 AHMC endorses the 5-step C3 Protocol
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
3 C Protocols
bull Developed by ACSQHC for other disciplinesndash General Radiologyndash Ultrasoundndash CT amp MRIndash Interventional Radiologyndash Nuclear Medicinendash Oral Surgeryndash Simulation Radiation Therapyndash Treatment Radiation Therapy
bull Four stage process
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
3 C Protocols conthellip
bull Four stage process1 Validation2 Matching3 Time out4 Post procedure
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Surgical Safety - Australian Response2004 AHMC endorses the 5-step C3 Protocol
2005 WA Correct PPS Policy 1st Ed
2006 Revised WA Correct PPS Policy
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Correct PPS Policy
Five Step Process1 Ensure that valid consent is
obtained2 Confirm the patientrsquos identity3 Mark the site of the surgery or
invasive procedure4 Take a final lsquoteam time outrsquo in the
operating theatre treatment or examination area
5 Ensure the correct and appropriate documents and diagnostic images are available
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Correct PPS Policy conthellip
bull Three stage process
1 Days to hours before procedure
2 Just before entering the operating theatre or treatment room
3 Immediately prior to the procedure
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Surgical Safety - Australian Response2004 AHMC endorses the 5-step C3 Protocol
2005 WA Correct PPS Policy 1st Ed
2006 Revised WA Correct PPS Policy
2008 National Compliance Audit C3 Protocolndash Variance amp deficits identified
2009 Local Compliance Audit (WA)ndash Variance amp deficits identified
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Correct PPS WA Audit Resultsbull Six hospital sites audited Oct 08 ndash Feb 09bull Considerable variance in compliance
ndash Obtaining valid consent (esp prior to administration of pre-surgery medication)
ndash Marking the surgical sitendash Final Team Time Out (esp verification of site marking
participation of anaesthetists)ndash Verification of documents amp diagnostic images
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Correct PPS WA Audit Resultsbull Six hospital sites audited Oct 08 ndash Feb 09bull Considerable variance in compliance
ndash Obtaining valid consent (esp prior to administration of pre-surgery medication)
ndash Marking the surgical sitendash Final Team Time Out (esp verification of site marking
participation of anaesthetists)ndash Verification of documents amp diagnostic images
RecommendationUpdate Correct PPS policy facilitate
implementation WHO Checklist
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Australian Response (cont)Nov 2009
ndash AHMC endorses the WHO Surgical Safety Checklist (Checklist) as agreed national strategy for surgical safety
ndash All jurisdictions to have implemented locally adapted versions by July 2011
Nov 2009ndash WA MDF endorses Checklist recommending that it be
implemented as minimum standard across WA Health
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
WHO Checklist Endorsementbull Royal Australasian College of Surgeonsbull Australian and New Zealand College of Anaesthetistsbull Royal Australian and New Zealand College of
Obstetricians and Gynaecologistsbull Royal Australian and New Zealand College of
Ophthalmologistsbull Australian College of Operating Room Nursesbull WA Medical Directorsrsquo Forum
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
WA Health Surgical Safety Checklistbull Developed throughout 2010 bull Extensive stakeholder consultation and strong
agreement consensusbull Contains ALL components of C3 Protocolbull Modest changes and adaptation to WA contextbull Rolled out in November 2010bull Operational Directive OD 031611 March 2011
httpwwwhealthwagovaucircularsnewcircularcfmCirc_ID=12773
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Adapted From
WHO SSC Implementation Manual (2009)
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
WA Health Surgical Safety Checklist (cont)
bull Minimum standardbull Sites health services can ADD elements and
move elements between phasesbull 3-phase structure must be preservedbull Signature verification that all elements have
been verbally confirmed
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
WHO Checklist Adaptation Principles
bull Each section Focusedconcisebull Each section Brief (one min per section)bull Each item Actionablebull Designed for Verbal usebull Collaborative method of adaptionbull Tested in real situations before endorsementbull Integrated into routine processes
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Next StepshellipOSQH
bull Revise WA Correct PPS Policyndash Policy framework for the WA Checklist
bull Continued liaison w ACSQHC re checklists for other specialties
bull Evaluation of WA Checklist 2012ndash Auditndash Surveysndash Other data sources (AIMS HDMS)
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Next Stepshellipyou
bull Understand Checklist amp evidence bull Identify key people
ndash SampQndash Surgical nursing leads
bull Get involvedndash Auditndash Adaptndash Participation
bull Introduce
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Contact
For further information or feedback contact
Tel (08) 9222 4080 Fax (08) 9222 4324 E-mail safetyandqualityhealthwagovauWeb httpwwwsafetyandqualityhealthwagovau
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
References1 Haynes B et al A surgical safety checklist to reduce morbidity and mortality in a
global population New England Journal of Medicine 2009 360 491-92 Gawande A The Checklist Manifesto ndash How to get things right 2009
MacMillan Press3 Hales BM Pronovost PJ The checklist--a tool for error management and
performance improvement Journal of Critical Care 2006 21(3)231-54 Semel ME Resch S Haynes AB Funk LM Bader A Berry WR Weiser TG
Gawande AA Adopting a surgical safety checklist could save money and improve the quality of care in US hospitals Health Affairs 2010 29(9)1593-9
5 Haynes B et al Changes in safety attitude and relationships to decreased postoperative morbidity and mortality following implementation of a checklist- based surgical safety intervention BMJ Qual Safety 2011 20102-7
6 httpwwwwhointpatientsafetysafesurgerytools_resourcesenindexhtml
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
WA Data ndash contributing factors 0809
bull Procedure (inclsurgery) involving wrong patientbody partndash Formal handoverndash ldquoteam time outrdquo proceduresndash Policy and procedures to be followedndash Formal patient identification protocolsndash Resources to ensure two staff verify patient
identification
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
WA Data ndash contributing factors 0809
bull Retained instruments or other material after surgery requiring re-operation or further surgical procedurendash Faulty equipmentndash Need for compliance with policy and proceduresndash Need for improved written and verbal information
during handoverndash Staff fatiguendash Experience of clinical staff involved
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Global challengehellip
bull 234 million major operations per year
bull 7 million people suffer complications per year
bull 1 million people die duringafter surgery per year
bull Developed worldndash 50 hospital harmful events surgical care amp services
ndash 50 of these (25 overall) preventable if standards of care are followed and safety tools used
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Safer Surgery Saving Livesbull 2008 ndash WHO Surgical Safety Checklist
developed
bull International trial indicated significant reduction in mortality and complication rates 1
bull Checklist adopted by health services across the world
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Safer Surgery Saving Livesbull 2008 ndash WHO Surgical Safety Checklist
developed
bull International trial indicated significant reduction in mortality and complication rates 1
bull Checklist adopted by health services across the world
Sir Liam Donaldson UK National Patient Safety Agency ldquoHospitals not using a surgical safety checklist are endangering patient safety If I were to need an operation I would want to be treated somewhere using a surgical checklistrdquo
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
CHECKLISTS ndash value and utilitybull Recognised safety mechanism bull Reduce risk of error by introducing redundancies into
processes bull Used across a range of industries including health
care where complex sequencing and communication are required 2 3
bull Can expedite patient flow through busy surgical wards and generate financial savings for hospitals 4
bull improve perceptions of teamwork and safety culture among clinicians which has been empirically linked to improved patient outcomes 5
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
WHO Checklistbull Designed for universal flow of proceduresbull Arranged into three phases SIGN IN ndash TIME
OUT ndash SIGN OUTbull Ensures correct patient site and sidebull Addresses other potential errors bull Minimises complications of surgerybull Ensures best possible post-procedure patient
care
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Surgical Safety - Australian Response
2004 AHMC endorses the 5-step C3 Protocol
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
3 C Protocols
bull Developed by ACSQHC for other disciplinesndash General Radiologyndash Ultrasoundndash CT amp MRIndash Interventional Radiologyndash Nuclear Medicinendash Oral Surgeryndash Simulation Radiation Therapyndash Treatment Radiation Therapy
bull Four stage process
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
3 C Protocols conthellip
bull Four stage process1 Validation2 Matching3 Time out4 Post procedure
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Surgical Safety - Australian Response2004 AHMC endorses the 5-step C3 Protocol
2005 WA Correct PPS Policy 1st Ed
2006 Revised WA Correct PPS Policy
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Correct PPS Policy
Five Step Process1 Ensure that valid consent is
obtained2 Confirm the patientrsquos identity3 Mark the site of the surgery or
invasive procedure4 Take a final lsquoteam time outrsquo in the
operating theatre treatment or examination area
5 Ensure the correct and appropriate documents and diagnostic images are available
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Correct PPS Policy conthellip
bull Three stage process
1 Days to hours before procedure
2 Just before entering the operating theatre or treatment room
3 Immediately prior to the procedure
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Surgical Safety - Australian Response2004 AHMC endorses the 5-step C3 Protocol
2005 WA Correct PPS Policy 1st Ed
2006 Revised WA Correct PPS Policy
2008 National Compliance Audit C3 Protocolndash Variance amp deficits identified
2009 Local Compliance Audit (WA)ndash Variance amp deficits identified
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Correct PPS WA Audit Resultsbull Six hospital sites audited Oct 08 ndash Feb 09bull Considerable variance in compliance
ndash Obtaining valid consent (esp prior to administration of pre-surgery medication)
ndash Marking the surgical sitendash Final Team Time Out (esp verification of site marking
participation of anaesthetists)ndash Verification of documents amp diagnostic images
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Correct PPS WA Audit Resultsbull Six hospital sites audited Oct 08 ndash Feb 09bull Considerable variance in compliance
ndash Obtaining valid consent (esp prior to administration of pre-surgery medication)
ndash Marking the surgical sitendash Final Team Time Out (esp verification of site marking
participation of anaesthetists)ndash Verification of documents amp diagnostic images
RecommendationUpdate Correct PPS policy facilitate
implementation WHO Checklist
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Australian Response (cont)Nov 2009
ndash AHMC endorses the WHO Surgical Safety Checklist (Checklist) as agreed national strategy for surgical safety
ndash All jurisdictions to have implemented locally adapted versions by July 2011
Nov 2009ndash WA MDF endorses Checklist recommending that it be
implemented as minimum standard across WA Health
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
WHO Checklist Endorsementbull Royal Australasian College of Surgeonsbull Australian and New Zealand College of Anaesthetistsbull Royal Australian and New Zealand College of
Obstetricians and Gynaecologistsbull Royal Australian and New Zealand College of
Ophthalmologistsbull Australian College of Operating Room Nursesbull WA Medical Directorsrsquo Forum
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
WA Health Surgical Safety Checklistbull Developed throughout 2010 bull Extensive stakeholder consultation and strong
agreement consensusbull Contains ALL components of C3 Protocolbull Modest changes and adaptation to WA contextbull Rolled out in November 2010bull Operational Directive OD 031611 March 2011
httpwwwhealthwagovaucircularsnewcircularcfmCirc_ID=12773
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Adapted From
WHO SSC Implementation Manual (2009)
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
WA Health Surgical Safety Checklist (cont)
bull Minimum standardbull Sites health services can ADD elements and
move elements between phasesbull 3-phase structure must be preservedbull Signature verification that all elements have
been verbally confirmed
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
WHO Checklist Adaptation Principles
bull Each section Focusedconcisebull Each section Brief (one min per section)bull Each item Actionablebull Designed for Verbal usebull Collaborative method of adaptionbull Tested in real situations before endorsementbull Integrated into routine processes
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Next StepshellipOSQH
bull Revise WA Correct PPS Policyndash Policy framework for the WA Checklist
bull Continued liaison w ACSQHC re checklists for other specialties
bull Evaluation of WA Checklist 2012ndash Auditndash Surveysndash Other data sources (AIMS HDMS)
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Next Stepshellipyou
bull Understand Checklist amp evidence bull Identify key people
ndash SampQndash Surgical nursing leads
bull Get involvedndash Auditndash Adaptndash Participation
bull Introduce
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Contact
For further information or feedback contact
Tel (08) 9222 4080 Fax (08) 9222 4324 E-mail safetyandqualityhealthwagovauWeb httpwwwsafetyandqualityhealthwagovau
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
References1 Haynes B et al A surgical safety checklist to reduce morbidity and mortality in a
global population New England Journal of Medicine 2009 360 491-92 Gawande A The Checklist Manifesto ndash How to get things right 2009
MacMillan Press3 Hales BM Pronovost PJ The checklist--a tool for error management and
performance improvement Journal of Critical Care 2006 21(3)231-54 Semel ME Resch S Haynes AB Funk LM Bader A Berry WR Weiser TG
Gawande AA Adopting a surgical safety checklist could save money and improve the quality of care in US hospitals Health Affairs 2010 29(9)1593-9
5 Haynes B et al Changes in safety attitude and relationships to decreased postoperative morbidity and mortality following implementation of a checklist- based surgical safety intervention BMJ Qual Safety 2011 20102-7
6 httpwwwwhointpatientsafetysafesurgerytools_resourcesenindexhtml
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
WA Data ndash contributing factors 0809
bull Retained instruments or other material after surgery requiring re-operation or further surgical procedurendash Faulty equipmentndash Need for compliance with policy and proceduresndash Need for improved written and verbal information
during handoverndash Staff fatiguendash Experience of clinical staff involved
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Global challengehellip
bull 234 million major operations per year
bull 7 million people suffer complications per year
bull 1 million people die duringafter surgery per year
bull Developed worldndash 50 hospital harmful events surgical care amp services
ndash 50 of these (25 overall) preventable if standards of care are followed and safety tools used
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Safer Surgery Saving Livesbull 2008 ndash WHO Surgical Safety Checklist
developed
bull International trial indicated significant reduction in mortality and complication rates 1
bull Checklist adopted by health services across the world
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Safer Surgery Saving Livesbull 2008 ndash WHO Surgical Safety Checklist
developed
bull International trial indicated significant reduction in mortality and complication rates 1
bull Checklist adopted by health services across the world
Sir Liam Donaldson UK National Patient Safety Agency ldquoHospitals not using a surgical safety checklist are endangering patient safety If I were to need an operation I would want to be treated somewhere using a surgical checklistrdquo
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
CHECKLISTS ndash value and utilitybull Recognised safety mechanism bull Reduce risk of error by introducing redundancies into
processes bull Used across a range of industries including health
care where complex sequencing and communication are required 2 3
bull Can expedite patient flow through busy surgical wards and generate financial savings for hospitals 4
bull improve perceptions of teamwork and safety culture among clinicians which has been empirically linked to improved patient outcomes 5
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
WHO Checklistbull Designed for universal flow of proceduresbull Arranged into three phases SIGN IN ndash TIME
OUT ndash SIGN OUTbull Ensures correct patient site and sidebull Addresses other potential errors bull Minimises complications of surgerybull Ensures best possible post-procedure patient
care
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Surgical Safety - Australian Response
2004 AHMC endorses the 5-step C3 Protocol
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
3 C Protocols
bull Developed by ACSQHC for other disciplinesndash General Radiologyndash Ultrasoundndash CT amp MRIndash Interventional Radiologyndash Nuclear Medicinendash Oral Surgeryndash Simulation Radiation Therapyndash Treatment Radiation Therapy
bull Four stage process
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
3 C Protocols conthellip
bull Four stage process1 Validation2 Matching3 Time out4 Post procedure
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Surgical Safety - Australian Response2004 AHMC endorses the 5-step C3 Protocol
2005 WA Correct PPS Policy 1st Ed
2006 Revised WA Correct PPS Policy
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Correct PPS Policy
Five Step Process1 Ensure that valid consent is
obtained2 Confirm the patientrsquos identity3 Mark the site of the surgery or
invasive procedure4 Take a final lsquoteam time outrsquo in the
operating theatre treatment or examination area
5 Ensure the correct and appropriate documents and diagnostic images are available
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Correct PPS Policy conthellip
bull Three stage process
1 Days to hours before procedure
2 Just before entering the operating theatre or treatment room
3 Immediately prior to the procedure
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Surgical Safety - Australian Response2004 AHMC endorses the 5-step C3 Protocol
2005 WA Correct PPS Policy 1st Ed
2006 Revised WA Correct PPS Policy
2008 National Compliance Audit C3 Protocolndash Variance amp deficits identified
2009 Local Compliance Audit (WA)ndash Variance amp deficits identified
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Correct PPS WA Audit Resultsbull Six hospital sites audited Oct 08 ndash Feb 09bull Considerable variance in compliance
ndash Obtaining valid consent (esp prior to administration of pre-surgery medication)
ndash Marking the surgical sitendash Final Team Time Out (esp verification of site marking
participation of anaesthetists)ndash Verification of documents amp diagnostic images
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Correct PPS WA Audit Resultsbull Six hospital sites audited Oct 08 ndash Feb 09bull Considerable variance in compliance
ndash Obtaining valid consent (esp prior to administration of pre-surgery medication)
ndash Marking the surgical sitendash Final Team Time Out (esp verification of site marking
participation of anaesthetists)ndash Verification of documents amp diagnostic images
RecommendationUpdate Correct PPS policy facilitate
implementation WHO Checklist
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Australian Response (cont)Nov 2009
ndash AHMC endorses the WHO Surgical Safety Checklist (Checklist) as agreed national strategy for surgical safety
ndash All jurisdictions to have implemented locally adapted versions by July 2011
Nov 2009ndash WA MDF endorses Checklist recommending that it be
implemented as minimum standard across WA Health
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
WHO Checklist Endorsementbull Royal Australasian College of Surgeonsbull Australian and New Zealand College of Anaesthetistsbull Royal Australian and New Zealand College of
Obstetricians and Gynaecologistsbull Royal Australian and New Zealand College of
Ophthalmologistsbull Australian College of Operating Room Nursesbull WA Medical Directorsrsquo Forum
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
WA Health Surgical Safety Checklistbull Developed throughout 2010 bull Extensive stakeholder consultation and strong
agreement consensusbull Contains ALL components of C3 Protocolbull Modest changes and adaptation to WA contextbull Rolled out in November 2010bull Operational Directive OD 031611 March 2011
httpwwwhealthwagovaucircularsnewcircularcfmCirc_ID=12773
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Adapted From
WHO SSC Implementation Manual (2009)
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
WA Health Surgical Safety Checklist (cont)
bull Minimum standardbull Sites health services can ADD elements and
move elements between phasesbull 3-phase structure must be preservedbull Signature verification that all elements have
been verbally confirmed
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
WHO Checklist Adaptation Principles
bull Each section Focusedconcisebull Each section Brief (one min per section)bull Each item Actionablebull Designed for Verbal usebull Collaborative method of adaptionbull Tested in real situations before endorsementbull Integrated into routine processes
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Next StepshellipOSQH
bull Revise WA Correct PPS Policyndash Policy framework for the WA Checklist
bull Continued liaison w ACSQHC re checklists for other specialties
bull Evaluation of WA Checklist 2012ndash Auditndash Surveysndash Other data sources (AIMS HDMS)
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Next Stepshellipyou
bull Understand Checklist amp evidence bull Identify key people
ndash SampQndash Surgical nursing leads
bull Get involvedndash Auditndash Adaptndash Participation
bull Introduce
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Contact
For further information or feedback contact
Tel (08) 9222 4080 Fax (08) 9222 4324 E-mail safetyandqualityhealthwagovauWeb httpwwwsafetyandqualityhealthwagovau
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
References1 Haynes B et al A surgical safety checklist to reduce morbidity and mortality in a
global population New England Journal of Medicine 2009 360 491-92 Gawande A The Checklist Manifesto ndash How to get things right 2009
MacMillan Press3 Hales BM Pronovost PJ The checklist--a tool for error management and
performance improvement Journal of Critical Care 2006 21(3)231-54 Semel ME Resch S Haynes AB Funk LM Bader A Berry WR Weiser TG
Gawande AA Adopting a surgical safety checklist could save money and improve the quality of care in US hospitals Health Affairs 2010 29(9)1593-9
5 Haynes B et al Changes in safety attitude and relationships to decreased postoperative morbidity and mortality following implementation of a checklist- based surgical safety intervention BMJ Qual Safety 2011 20102-7
6 httpwwwwhointpatientsafetysafesurgerytools_resourcesenindexhtml
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Global challengehellip
bull 234 million major operations per year
bull 7 million people suffer complications per year
bull 1 million people die duringafter surgery per year
bull Developed worldndash 50 hospital harmful events surgical care amp services
ndash 50 of these (25 overall) preventable if standards of care are followed and safety tools used
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Safer Surgery Saving Livesbull 2008 ndash WHO Surgical Safety Checklist
developed
bull International trial indicated significant reduction in mortality and complication rates 1
bull Checklist adopted by health services across the world
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Safer Surgery Saving Livesbull 2008 ndash WHO Surgical Safety Checklist
developed
bull International trial indicated significant reduction in mortality and complication rates 1
bull Checklist adopted by health services across the world
Sir Liam Donaldson UK National Patient Safety Agency ldquoHospitals not using a surgical safety checklist are endangering patient safety If I were to need an operation I would want to be treated somewhere using a surgical checklistrdquo
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
CHECKLISTS ndash value and utilitybull Recognised safety mechanism bull Reduce risk of error by introducing redundancies into
processes bull Used across a range of industries including health
care where complex sequencing and communication are required 2 3
bull Can expedite patient flow through busy surgical wards and generate financial savings for hospitals 4
bull improve perceptions of teamwork and safety culture among clinicians which has been empirically linked to improved patient outcomes 5
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
WHO Checklistbull Designed for universal flow of proceduresbull Arranged into three phases SIGN IN ndash TIME
OUT ndash SIGN OUTbull Ensures correct patient site and sidebull Addresses other potential errors bull Minimises complications of surgerybull Ensures best possible post-procedure patient
care
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Surgical Safety - Australian Response
2004 AHMC endorses the 5-step C3 Protocol
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
3 C Protocols
bull Developed by ACSQHC for other disciplinesndash General Radiologyndash Ultrasoundndash CT amp MRIndash Interventional Radiologyndash Nuclear Medicinendash Oral Surgeryndash Simulation Radiation Therapyndash Treatment Radiation Therapy
bull Four stage process
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
3 C Protocols conthellip
bull Four stage process1 Validation2 Matching3 Time out4 Post procedure
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Surgical Safety - Australian Response2004 AHMC endorses the 5-step C3 Protocol
2005 WA Correct PPS Policy 1st Ed
2006 Revised WA Correct PPS Policy
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Correct PPS Policy
Five Step Process1 Ensure that valid consent is
obtained2 Confirm the patientrsquos identity3 Mark the site of the surgery or
invasive procedure4 Take a final lsquoteam time outrsquo in the
operating theatre treatment or examination area
5 Ensure the correct and appropriate documents and diagnostic images are available
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Correct PPS Policy conthellip
bull Three stage process
1 Days to hours before procedure
2 Just before entering the operating theatre or treatment room
3 Immediately prior to the procedure
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Surgical Safety - Australian Response2004 AHMC endorses the 5-step C3 Protocol
2005 WA Correct PPS Policy 1st Ed
2006 Revised WA Correct PPS Policy
2008 National Compliance Audit C3 Protocolndash Variance amp deficits identified
2009 Local Compliance Audit (WA)ndash Variance amp deficits identified
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Correct PPS WA Audit Resultsbull Six hospital sites audited Oct 08 ndash Feb 09bull Considerable variance in compliance
ndash Obtaining valid consent (esp prior to administration of pre-surgery medication)
ndash Marking the surgical sitendash Final Team Time Out (esp verification of site marking
participation of anaesthetists)ndash Verification of documents amp diagnostic images
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Correct PPS WA Audit Resultsbull Six hospital sites audited Oct 08 ndash Feb 09bull Considerable variance in compliance
ndash Obtaining valid consent (esp prior to administration of pre-surgery medication)
ndash Marking the surgical sitendash Final Team Time Out (esp verification of site marking
participation of anaesthetists)ndash Verification of documents amp diagnostic images
RecommendationUpdate Correct PPS policy facilitate
implementation WHO Checklist
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Australian Response (cont)Nov 2009
ndash AHMC endorses the WHO Surgical Safety Checklist (Checklist) as agreed national strategy for surgical safety
ndash All jurisdictions to have implemented locally adapted versions by July 2011
Nov 2009ndash WA MDF endorses Checklist recommending that it be
implemented as minimum standard across WA Health
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
WHO Checklist Endorsementbull Royal Australasian College of Surgeonsbull Australian and New Zealand College of Anaesthetistsbull Royal Australian and New Zealand College of
Obstetricians and Gynaecologistsbull Royal Australian and New Zealand College of
Ophthalmologistsbull Australian College of Operating Room Nursesbull WA Medical Directorsrsquo Forum
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
WA Health Surgical Safety Checklistbull Developed throughout 2010 bull Extensive stakeholder consultation and strong
agreement consensusbull Contains ALL components of C3 Protocolbull Modest changes and adaptation to WA contextbull Rolled out in November 2010bull Operational Directive OD 031611 March 2011
httpwwwhealthwagovaucircularsnewcircularcfmCirc_ID=12773
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Adapted From
WHO SSC Implementation Manual (2009)
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
WA Health Surgical Safety Checklist (cont)
bull Minimum standardbull Sites health services can ADD elements and
move elements between phasesbull 3-phase structure must be preservedbull Signature verification that all elements have
been verbally confirmed
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
WHO Checklist Adaptation Principles
bull Each section Focusedconcisebull Each section Brief (one min per section)bull Each item Actionablebull Designed for Verbal usebull Collaborative method of adaptionbull Tested in real situations before endorsementbull Integrated into routine processes
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Next StepshellipOSQH
bull Revise WA Correct PPS Policyndash Policy framework for the WA Checklist
bull Continued liaison w ACSQHC re checklists for other specialties
bull Evaluation of WA Checklist 2012ndash Auditndash Surveysndash Other data sources (AIMS HDMS)
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Next Stepshellipyou
bull Understand Checklist amp evidence bull Identify key people
ndash SampQndash Surgical nursing leads
bull Get involvedndash Auditndash Adaptndash Participation
bull Introduce
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Contact
For further information or feedback contact
Tel (08) 9222 4080 Fax (08) 9222 4324 E-mail safetyandqualityhealthwagovauWeb httpwwwsafetyandqualityhealthwagovau
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
References1 Haynes B et al A surgical safety checklist to reduce morbidity and mortality in a
global population New England Journal of Medicine 2009 360 491-92 Gawande A The Checklist Manifesto ndash How to get things right 2009
MacMillan Press3 Hales BM Pronovost PJ The checklist--a tool for error management and
performance improvement Journal of Critical Care 2006 21(3)231-54 Semel ME Resch S Haynes AB Funk LM Bader A Berry WR Weiser TG
Gawande AA Adopting a surgical safety checklist could save money and improve the quality of care in US hospitals Health Affairs 2010 29(9)1593-9
5 Haynes B et al Changes in safety attitude and relationships to decreased postoperative morbidity and mortality following implementation of a checklist- based surgical safety intervention BMJ Qual Safety 2011 20102-7
6 httpwwwwhointpatientsafetysafesurgerytools_resourcesenindexhtml
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Safer Surgery Saving Livesbull 2008 ndash WHO Surgical Safety Checklist
developed
bull International trial indicated significant reduction in mortality and complication rates 1
bull Checklist adopted by health services across the world
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Safer Surgery Saving Livesbull 2008 ndash WHO Surgical Safety Checklist
developed
bull International trial indicated significant reduction in mortality and complication rates 1
bull Checklist adopted by health services across the world
Sir Liam Donaldson UK National Patient Safety Agency ldquoHospitals not using a surgical safety checklist are endangering patient safety If I were to need an operation I would want to be treated somewhere using a surgical checklistrdquo
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
CHECKLISTS ndash value and utilitybull Recognised safety mechanism bull Reduce risk of error by introducing redundancies into
processes bull Used across a range of industries including health
care where complex sequencing and communication are required 2 3
bull Can expedite patient flow through busy surgical wards and generate financial savings for hospitals 4
bull improve perceptions of teamwork and safety culture among clinicians which has been empirically linked to improved patient outcomes 5
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
WHO Checklistbull Designed for universal flow of proceduresbull Arranged into three phases SIGN IN ndash TIME
OUT ndash SIGN OUTbull Ensures correct patient site and sidebull Addresses other potential errors bull Minimises complications of surgerybull Ensures best possible post-procedure patient
care
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Surgical Safety - Australian Response
2004 AHMC endorses the 5-step C3 Protocol
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
3 C Protocols
bull Developed by ACSQHC for other disciplinesndash General Radiologyndash Ultrasoundndash CT amp MRIndash Interventional Radiologyndash Nuclear Medicinendash Oral Surgeryndash Simulation Radiation Therapyndash Treatment Radiation Therapy
bull Four stage process
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
3 C Protocols conthellip
bull Four stage process1 Validation2 Matching3 Time out4 Post procedure
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Surgical Safety - Australian Response2004 AHMC endorses the 5-step C3 Protocol
2005 WA Correct PPS Policy 1st Ed
2006 Revised WA Correct PPS Policy
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Correct PPS Policy
Five Step Process1 Ensure that valid consent is
obtained2 Confirm the patientrsquos identity3 Mark the site of the surgery or
invasive procedure4 Take a final lsquoteam time outrsquo in the
operating theatre treatment or examination area
5 Ensure the correct and appropriate documents and diagnostic images are available
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Correct PPS Policy conthellip
bull Three stage process
1 Days to hours before procedure
2 Just before entering the operating theatre or treatment room
3 Immediately prior to the procedure
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Surgical Safety - Australian Response2004 AHMC endorses the 5-step C3 Protocol
2005 WA Correct PPS Policy 1st Ed
2006 Revised WA Correct PPS Policy
2008 National Compliance Audit C3 Protocolndash Variance amp deficits identified
2009 Local Compliance Audit (WA)ndash Variance amp deficits identified
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Correct PPS WA Audit Resultsbull Six hospital sites audited Oct 08 ndash Feb 09bull Considerable variance in compliance
ndash Obtaining valid consent (esp prior to administration of pre-surgery medication)
ndash Marking the surgical sitendash Final Team Time Out (esp verification of site marking
participation of anaesthetists)ndash Verification of documents amp diagnostic images
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Correct PPS WA Audit Resultsbull Six hospital sites audited Oct 08 ndash Feb 09bull Considerable variance in compliance
ndash Obtaining valid consent (esp prior to administration of pre-surgery medication)
ndash Marking the surgical sitendash Final Team Time Out (esp verification of site marking
participation of anaesthetists)ndash Verification of documents amp diagnostic images
RecommendationUpdate Correct PPS policy facilitate
implementation WHO Checklist
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Australian Response (cont)Nov 2009
ndash AHMC endorses the WHO Surgical Safety Checklist (Checklist) as agreed national strategy for surgical safety
ndash All jurisdictions to have implemented locally adapted versions by July 2011
Nov 2009ndash WA MDF endorses Checklist recommending that it be
implemented as minimum standard across WA Health
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
WHO Checklist Endorsementbull Royal Australasian College of Surgeonsbull Australian and New Zealand College of Anaesthetistsbull Royal Australian and New Zealand College of
Obstetricians and Gynaecologistsbull Royal Australian and New Zealand College of
Ophthalmologistsbull Australian College of Operating Room Nursesbull WA Medical Directorsrsquo Forum
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
WA Health Surgical Safety Checklistbull Developed throughout 2010 bull Extensive stakeholder consultation and strong
agreement consensusbull Contains ALL components of C3 Protocolbull Modest changes and adaptation to WA contextbull Rolled out in November 2010bull Operational Directive OD 031611 March 2011
httpwwwhealthwagovaucircularsnewcircularcfmCirc_ID=12773
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Adapted From
WHO SSC Implementation Manual (2009)
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
WA Health Surgical Safety Checklist (cont)
bull Minimum standardbull Sites health services can ADD elements and
move elements between phasesbull 3-phase structure must be preservedbull Signature verification that all elements have
been verbally confirmed
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
WHO Checklist Adaptation Principles
bull Each section Focusedconcisebull Each section Brief (one min per section)bull Each item Actionablebull Designed for Verbal usebull Collaborative method of adaptionbull Tested in real situations before endorsementbull Integrated into routine processes
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Next StepshellipOSQH
bull Revise WA Correct PPS Policyndash Policy framework for the WA Checklist
bull Continued liaison w ACSQHC re checklists for other specialties
bull Evaluation of WA Checklist 2012ndash Auditndash Surveysndash Other data sources (AIMS HDMS)
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Next Stepshellipyou
bull Understand Checklist amp evidence bull Identify key people
ndash SampQndash Surgical nursing leads
bull Get involvedndash Auditndash Adaptndash Participation
bull Introduce
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Contact
For further information or feedback contact
Tel (08) 9222 4080 Fax (08) 9222 4324 E-mail safetyandqualityhealthwagovauWeb httpwwwsafetyandqualityhealthwagovau
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
References1 Haynes B et al A surgical safety checklist to reduce morbidity and mortality in a
global population New England Journal of Medicine 2009 360 491-92 Gawande A The Checklist Manifesto ndash How to get things right 2009
MacMillan Press3 Hales BM Pronovost PJ The checklist--a tool for error management and
performance improvement Journal of Critical Care 2006 21(3)231-54 Semel ME Resch S Haynes AB Funk LM Bader A Berry WR Weiser TG
Gawande AA Adopting a surgical safety checklist could save money and improve the quality of care in US hospitals Health Affairs 2010 29(9)1593-9
5 Haynes B et al Changes in safety attitude and relationships to decreased postoperative morbidity and mortality following implementation of a checklist- based surgical safety intervention BMJ Qual Safety 2011 20102-7
6 httpwwwwhointpatientsafetysafesurgerytools_resourcesenindexhtml
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Safer Surgery Saving Livesbull 2008 ndash WHO Surgical Safety Checklist
developed
bull International trial indicated significant reduction in mortality and complication rates 1
bull Checklist adopted by health services across the world
Sir Liam Donaldson UK National Patient Safety Agency ldquoHospitals not using a surgical safety checklist are endangering patient safety If I were to need an operation I would want to be treated somewhere using a surgical checklistrdquo
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
CHECKLISTS ndash value and utilitybull Recognised safety mechanism bull Reduce risk of error by introducing redundancies into
processes bull Used across a range of industries including health
care where complex sequencing and communication are required 2 3
bull Can expedite patient flow through busy surgical wards and generate financial savings for hospitals 4
bull improve perceptions of teamwork and safety culture among clinicians which has been empirically linked to improved patient outcomes 5
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
WHO Checklistbull Designed for universal flow of proceduresbull Arranged into three phases SIGN IN ndash TIME
OUT ndash SIGN OUTbull Ensures correct patient site and sidebull Addresses other potential errors bull Minimises complications of surgerybull Ensures best possible post-procedure patient
care
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Surgical Safety - Australian Response
2004 AHMC endorses the 5-step C3 Protocol
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
3 C Protocols
bull Developed by ACSQHC for other disciplinesndash General Radiologyndash Ultrasoundndash CT amp MRIndash Interventional Radiologyndash Nuclear Medicinendash Oral Surgeryndash Simulation Radiation Therapyndash Treatment Radiation Therapy
bull Four stage process
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
3 C Protocols conthellip
bull Four stage process1 Validation2 Matching3 Time out4 Post procedure
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Surgical Safety - Australian Response2004 AHMC endorses the 5-step C3 Protocol
2005 WA Correct PPS Policy 1st Ed
2006 Revised WA Correct PPS Policy
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Correct PPS Policy
Five Step Process1 Ensure that valid consent is
obtained2 Confirm the patientrsquos identity3 Mark the site of the surgery or
invasive procedure4 Take a final lsquoteam time outrsquo in the
operating theatre treatment or examination area
5 Ensure the correct and appropriate documents and diagnostic images are available
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Correct PPS Policy conthellip
bull Three stage process
1 Days to hours before procedure
2 Just before entering the operating theatre or treatment room
3 Immediately prior to the procedure
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Surgical Safety - Australian Response2004 AHMC endorses the 5-step C3 Protocol
2005 WA Correct PPS Policy 1st Ed
2006 Revised WA Correct PPS Policy
2008 National Compliance Audit C3 Protocolndash Variance amp deficits identified
2009 Local Compliance Audit (WA)ndash Variance amp deficits identified
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Correct PPS WA Audit Resultsbull Six hospital sites audited Oct 08 ndash Feb 09bull Considerable variance in compliance
ndash Obtaining valid consent (esp prior to administration of pre-surgery medication)
ndash Marking the surgical sitendash Final Team Time Out (esp verification of site marking
participation of anaesthetists)ndash Verification of documents amp diagnostic images
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Correct PPS WA Audit Resultsbull Six hospital sites audited Oct 08 ndash Feb 09bull Considerable variance in compliance
ndash Obtaining valid consent (esp prior to administration of pre-surgery medication)
ndash Marking the surgical sitendash Final Team Time Out (esp verification of site marking
participation of anaesthetists)ndash Verification of documents amp diagnostic images
RecommendationUpdate Correct PPS policy facilitate
implementation WHO Checklist
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Australian Response (cont)Nov 2009
ndash AHMC endorses the WHO Surgical Safety Checklist (Checklist) as agreed national strategy for surgical safety
ndash All jurisdictions to have implemented locally adapted versions by July 2011
Nov 2009ndash WA MDF endorses Checklist recommending that it be
implemented as minimum standard across WA Health
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
WHO Checklist Endorsementbull Royal Australasian College of Surgeonsbull Australian and New Zealand College of Anaesthetistsbull Royal Australian and New Zealand College of
Obstetricians and Gynaecologistsbull Royal Australian and New Zealand College of
Ophthalmologistsbull Australian College of Operating Room Nursesbull WA Medical Directorsrsquo Forum
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
WA Health Surgical Safety Checklistbull Developed throughout 2010 bull Extensive stakeholder consultation and strong
agreement consensusbull Contains ALL components of C3 Protocolbull Modest changes and adaptation to WA contextbull Rolled out in November 2010bull Operational Directive OD 031611 March 2011
httpwwwhealthwagovaucircularsnewcircularcfmCirc_ID=12773
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Adapted From
WHO SSC Implementation Manual (2009)
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
WA Health Surgical Safety Checklist (cont)
bull Minimum standardbull Sites health services can ADD elements and
move elements between phasesbull 3-phase structure must be preservedbull Signature verification that all elements have
been verbally confirmed
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
WHO Checklist Adaptation Principles
bull Each section Focusedconcisebull Each section Brief (one min per section)bull Each item Actionablebull Designed for Verbal usebull Collaborative method of adaptionbull Tested in real situations before endorsementbull Integrated into routine processes
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Next StepshellipOSQH
bull Revise WA Correct PPS Policyndash Policy framework for the WA Checklist
bull Continued liaison w ACSQHC re checklists for other specialties
bull Evaluation of WA Checklist 2012ndash Auditndash Surveysndash Other data sources (AIMS HDMS)
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Next Stepshellipyou
bull Understand Checklist amp evidence bull Identify key people
ndash SampQndash Surgical nursing leads
bull Get involvedndash Auditndash Adaptndash Participation
bull Introduce
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Contact
For further information or feedback contact
Tel (08) 9222 4080 Fax (08) 9222 4324 E-mail safetyandqualityhealthwagovauWeb httpwwwsafetyandqualityhealthwagovau
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
References1 Haynes B et al A surgical safety checklist to reduce morbidity and mortality in a
global population New England Journal of Medicine 2009 360 491-92 Gawande A The Checklist Manifesto ndash How to get things right 2009
MacMillan Press3 Hales BM Pronovost PJ The checklist--a tool for error management and
performance improvement Journal of Critical Care 2006 21(3)231-54 Semel ME Resch S Haynes AB Funk LM Bader A Berry WR Weiser TG
Gawande AA Adopting a surgical safety checklist could save money and improve the quality of care in US hospitals Health Affairs 2010 29(9)1593-9
5 Haynes B et al Changes in safety attitude and relationships to decreased postoperative morbidity and mortality following implementation of a checklist- based surgical safety intervention BMJ Qual Safety 2011 20102-7
6 httpwwwwhointpatientsafetysafesurgerytools_resourcesenindexhtml
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
CHECKLISTS ndash value and utilitybull Recognised safety mechanism bull Reduce risk of error by introducing redundancies into
processes bull Used across a range of industries including health
care where complex sequencing and communication are required 2 3
bull Can expedite patient flow through busy surgical wards and generate financial savings for hospitals 4
bull improve perceptions of teamwork and safety culture among clinicians which has been empirically linked to improved patient outcomes 5
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
WHO Checklistbull Designed for universal flow of proceduresbull Arranged into three phases SIGN IN ndash TIME
OUT ndash SIGN OUTbull Ensures correct patient site and sidebull Addresses other potential errors bull Minimises complications of surgerybull Ensures best possible post-procedure patient
care
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Surgical Safety - Australian Response
2004 AHMC endorses the 5-step C3 Protocol
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
3 C Protocols
bull Developed by ACSQHC for other disciplinesndash General Radiologyndash Ultrasoundndash CT amp MRIndash Interventional Radiologyndash Nuclear Medicinendash Oral Surgeryndash Simulation Radiation Therapyndash Treatment Radiation Therapy
bull Four stage process
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
3 C Protocols conthellip
bull Four stage process1 Validation2 Matching3 Time out4 Post procedure
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Surgical Safety - Australian Response2004 AHMC endorses the 5-step C3 Protocol
2005 WA Correct PPS Policy 1st Ed
2006 Revised WA Correct PPS Policy
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Correct PPS Policy
Five Step Process1 Ensure that valid consent is
obtained2 Confirm the patientrsquos identity3 Mark the site of the surgery or
invasive procedure4 Take a final lsquoteam time outrsquo in the
operating theatre treatment or examination area
5 Ensure the correct and appropriate documents and diagnostic images are available
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Correct PPS Policy conthellip
bull Three stage process
1 Days to hours before procedure
2 Just before entering the operating theatre or treatment room
3 Immediately prior to the procedure
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Surgical Safety - Australian Response2004 AHMC endorses the 5-step C3 Protocol
2005 WA Correct PPS Policy 1st Ed
2006 Revised WA Correct PPS Policy
2008 National Compliance Audit C3 Protocolndash Variance amp deficits identified
2009 Local Compliance Audit (WA)ndash Variance amp deficits identified
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Correct PPS WA Audit Resultsbull Six hospital sites audited Oct 08 ndash Feb 09bull Considerable variance in compliance
ndash Obtaining valid consent (esp prior to administration of pre-surgery medication)
ndash Marking the surgical sitendash Final Team Time Out (esp verification of site marking
participation of anaesthetists)ndash Verification of documents amp diagnostic images
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Correct PPS WA Audit Resultsbull Six hospital sites audited Oct 08 ndash Feb 09bull Considerable variance in compliance
ndash Obtaining valid consent (esp prior to administration of pre-surgery medication)
ndash Marking the surgical sitendash Final Team Time Out (esp verification of site marking
participation of anaesthetists)ndash Verification of documents amp diagnostic images
RecommendationUpdate Correct PPS policy facilitate
implementation WHO Checklist
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Australian Response (cont)Nov 2009
ndash AHMC endorses the WHO Surgical Safety Checklist (Checklist) as agreed national strategy for surgical safety
ndash All jurisdictions to have implemented locally adapted versions by July 2011
Nov 2009ndash WA MDF endorses Checklist recommending that it be
implemented as minimum standard across WA Health
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
WHO Checklist Endorsementbull Royal Australasian College of Surgeonsbull Australian and New Zealand College of Anaesthetistsbull Royal Australian and New Zealand College of
Obstetricians and Gynaecologistsbull Royal Australian and New Zealand College of
Ophthalmologistsbull Australian College of Operating Room Nursesbull WA Medical Directorsrsquo Forum
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
WA Health Surgical Safety Checklistbull Developed throughout 2010 bull Extensive stakeholder consultation and strong
agreement consensusbull Contains ALL components of C3 Protocolbull Modest changes and adaptation to WA contextbull Rolled out in November 2010bull Operational Directive OD 031611 March 2011
httpwwwhealthwagovaucircularsnewcircularcfmCirc_ID=12773
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Adapted From
WHO SSC Implementation Manual (2009)
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
WA Health Surgical Safety Checklist (cont)
bull Minimum standardbull Sites health services can ADD elements and
move elements between phasesbull 3-phase structure must be preservedbull Signature verification that all elements have
been verbally confirmed
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
WHO Checklist Adaptation Principles
bull Each section Focusedconcisebull Each section Brief (one min per section)bull Each item Actionablebull Designed for Verbal usebull Collaborative method of adaptionbull Tested in real situations before endorsementbull Integrated into routine processes
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Next StepshellipOSQH
bull Revise WA Correct PPS Policyndash Policy framework for the WA Checklist
bull Continued liaison w ACSQHC re checklists for other specialties
bull Evaluation of WA Checklist 2012ndash Auditndash Surveysndash Other data sources (AIMS HDMS)
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Next Stepshellipyou
bull Understand Checklist amp evidence bull Identify key people
ndash SampQndash Surgical nursing leads
bull Get involvedndash Auditndash Adaptndash Participation
bull Introduce
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Contact
For further information or feedback contact
Tel (08) 9222 4080 Fax (08) 9222 4324 E-mail safetyandqualityhealthwagovauWeb httpwwwsafetyandqualityhealthwagovau
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
References1 Haynes B et al A surgical safety checklist to reduce morbidity and mortality in a
global population New England Journal of Medicine 2009 360 491-92 Gawande A The Checklist Manifesto ndash How to get things right 2009
MacMillan Press3 Hales BM Pronovost PJ The checklist--a tool for error management and
performance improvement Journal of Critical Care 2006 21(3)231-54 Semel ME Resch S Haynes AB Funk LM Bader A Berry WR Weiser TG
Gawande AA Adopting a surgical safety checklist could save money and improve the quality of care in US hospitals Health Affairs 2010 29(9)1593-9
5 Haynes B et al Changes in safety attitude and relationships to decreased postoperative morbidity and mortality following implementation of a checklist- based surgical safety intervention BMJ Qual Safety 2011 20102-7
6 httpwwwwhointpatientsafetysafesurgerytools_resourcesenindexhtml
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
WHO Checklistbull Designed for universal flow of proceduresbull Arranged into three phases SIGN IN ndash TIME
OUT ndash SIGN OUTbull Ensures correct patient site and sidebull Addresses other potential errors bull Minimises complications of surgerybull Ensures best possible post-procedure patient
care
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Surgical Safety - Australian Response
2004 AHMC endorses the 5-step C3 Protocol
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
3 C Protocols
bull Developed by ACSQHC for other disciplinesndash General Radiologyndash Ultrasoundndash CT amp MRIndash Interventional Radiologyndash Nuclear Medicinendash Oral Surgeryndash Simulation Radiation Therapyndash Treatment Radiation Therapy
bull Four stage process
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
3 C Protocols conthellip
bull Four stage process1 Validation2 Matching3 Time out4 Post procedure
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Surgical Safety - Australian Response2004 AHMC endorses the 5-step C3 Protocol
2005 WA Correct PPS Policy 1st Ed
2006 Revised WA Correct PPS Policy
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Correct PPS Policy
Five Step Process1 Ensure that valid consent is
obtained2 Confirm the patientrsquos identity3 Mark the site of the surgery or
invasive procedure4 Take a final lsquoteam time outrsquo in the
operating theatre treatment or examination area
5 Ensure the correct and appropriate documents and diagnostic images are available
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Correct PPS Policy conthellip
bull Three stage process
1 Days to hours before procedure
2 Just before entering the operating theatre or treatment room
3 Immediately prior to the procedure
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Surgical Safety - Australian Response2004 AHMC endorses the 5-step C3 Protocol
2005 WA Correct PPS Policy 1st Ed
2006 Revised WA Correct PPS Policy
2008 National Compliance Audit C3 Protocolndash Variance amp deficits identified
2009 Local Compliance Audit (WA)ndash Variance amp deficits identified
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Correct PPS WA Audit Resultsbull Six hospital sites audited Oct 08 ndash Feb 09bull Considerable variance in compliance
ndash Obtaining valid consent (esp prior to administration of pre-surgery medication)
ndash Marking the surgical sitendash Final Team Time Out (esp verification of site marking
participation of anaesthetists)ndash Verification of documents amp diagnostic images
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Correct PPS WA Audit Resultsbull Six hospital sites audited Oct 08 ndash Feb 09bull Considerable variance in compliance
ndash Obtaining valid consent (esp prior to administration of pre-surgery medication)
ndash Marking the surgical sitendash Final Team Time Out (esp verification of site marking
participation of anaesthetists)ndash Verification of documents amp diagnostic images
RecommendationUpdate Correct PPS policy facilitate
implementation WHO Checklist
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Australian Response (cont)Nov 2009
ndash AHMC endorses the WHO Surgical Safety Checklist (Checklist) as agreed national strategy for surgical safety
ndash All jurisdictions to have implemented locally adapted versions by July 2011
Nov 2009ndash WA MDF endorses Checklist recommending that it be
implemented as minimum standard across WA Health
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
WHO Checklist Endorsementbull Royal Australasian College of Surgeonsbull Australian and New Zealand College of Anaesthetistsbull Royal Australian and New Zealand College of
Obstetricians and Gynaecologistsbull Royal Australian and New Zealand College of
Ophthalmologistsbull Australian College of Operating Room Nursesbull WA Medical Directorsrsquo Forum
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
WA Health Surgical Safety Checklistbull Developed throughout 2010 bull Extensive stakeholder consultation and strong
agreement consensusbull Contains ALL components of C3 Protocolbull Modest changes and adaptation to WA contextbull Rolled out in November 2010bull Operational Directive OD 031611 March 2011
httpwwwhealthwagovaucircularsnewcircularcfmCirc_ID=12773
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Adapted From
WHO SSC Implementation Manual (2009)
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
WA Health Surgical Safety Checklist (cont)
bull Minimum standardbull Sites health services can ADD elements and
move elements between phasesbull 3-phase structure must be preservedbull Signature verification that all elements have
been verbally confirmed
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
WHO Checklist Adaptation Principles
bull Each section Focusedconcisebull Each section Brief (one min per section)bull Each item Actionablebull Designed for Verbal usebull Collaborative method of adaptionbull Tested in real situations before endorsementbull Integrated into routine processes
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Next StepshellipOSQH
bull Revise WA Correct PPS Policyndash Policy framework for the WA Checklist
bull Continued liaison w ACSQHC re checklists for other specialties
bull Evaluation of WA Checklist 2012ndash Auditndash Surveysndash Other data sources (AIMS HDMS)
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Next Stepshellipyou
bull Understand Checklist amp evidence bull Identify key people
ndash SampQndash Surgical nursing leads
bull Get involvedndash Auditndash Adaptndash Participation
bull Introduce
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Contact
For further information or feedback contact
Tel (08) 9222 4080 Fax (08) 9222 4324 E-mail safetyandqualityhealthwagovauWeb httpwwwsafetyandqualityhealthwagovau
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
References1 Haynes B et al A surgical safety checklist to reduce morbidity and mortality in a
global population New England Journal of Medicine 2009 360 491-92 Gawande A The Checklist Manifesto ndash How to get things right 2009
MacMillan Press3 Hales BM Pronovost PJ The checklist--a tool for error management and
performance improvement Journal of Critical Care 2006 21(3)231-54 Semel ME Resch S Haynes AB Funk LM Bader A Berry WR Weiser TG
Gawande AA Adopting a surgical safety checklist could save money and improve the quality of care in US hospitals Health Affairs 2010 29(9)1593-9
5 Haynes B et al Changes in safety attitude and relationships to decreased postoperative morbidity and mortality following implementation of a checklist- based surgical safety intervention BMJ Qual Safety 2011 20102-7
6 httpwwwwhointpatientsafetysafesurgerytools_resourcesenindexhtml
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Surgical Safety - Australian Response
2004 AHMC endorses the 5-step C3 Protocol
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
3 C Protocols
bull Developed by ACSQHC for other disciplinesndash General Radiologyndash Ultrasoundndash CT amp MRIndash Interventional Radiologyndash Nuclear Medicinendash Oral Surgeryndash Simulation Radiation Therapyndash Treatment Radiation Therapy
bull Four stage process
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
3 C Protocols conthellip
bull Four stage process1 Validation2 Matching3 Time out4 Post procedure
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Surgical Safety - Australian Response2004 AHMC endorses the 5-step C3 Protocol
2005 WA Correct PPS Policy 1st Ed
2006 Revised WA Correct PPS Policy
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Correct PPS Policy
Five Step Process1 Ensure that valid consent is
obtained2 Confirm the patientrsquos identity3 Mark the site of the surgery or
invasive procedure4 Take a final lsquoteam time outrsquo in the
operating theatre treatment or examination area
5 Ensure the correct and appropriate documents and diagnostic images are available
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Correct PPS Policy conthellip
bull Three stage process
1 Days to hours before procedure
2 Just before entering the operating theatre or treatment room
3 Immediately prior to the procedure
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Surgical Safety - Australian Response2004 AHMC endorses the 5-step C3 Protocol
2005 WA Correct PPS Policy 1st Ed
2006 Revised WA Correct PPS Policy
2008 National Compliance Audit C3 Protocolndash Variance amp deficits identified
2009 Local Compliance Audit (WA)ndash Variance amp deficits identified
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Correct PPS WA Audit Resultsbull Six hospital sites audited Oct 08 ndash Feb 09bull Considerable variance in compliance
ndash Obtaining valid consent (esp prior to administration of pre-surgery medication)
ndash Marking the surgical sitendash Final Team Time Out (esp verification of site marking
participation of anaesthetists)ndash Verification of documents amp diagnostic images
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Correct PPS WA Audit Resultsbull Six hospital sites audited Oct 08 ndash Feb 09bull Considerable variance in compliance
ndash Obtaining valid consent (esp prior to administration of pre-surgery medication)
ndash Marking the surgical sitendash Final Team Time Out (esp verification of site marking
participation of anaesthetists)ndash Verification of documents amp diagnostic images
RecommendationUpdate Correct PPS policy facilitate
implementation WHO Checklist
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Australian Response (cont)Nov 2009
ndash AHMC endorses the WHO Surgical Safety Checklist (Checklist) as agreed national strategy for surgical safety
ndash All jurisdictions to have implemented locally adapted versions by July 2011
Nov 2009ndash WA MDF endorses Checklist recommending that it be
implemented as minimum standard across WA Health
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
WHO Checklist Endorsementbull Royal Australasian College of Surgeonsbull Australian and New Zealand College of Anaesthetistsbull Royal Australian and New Zealand College of
Obstetricians and Gynaecologistsbull Royal Australian and New Zealand College of
Ophthalmologistsbull Australian College of Operating Room Nursesbull WA Medical Directorsrsquo Forum
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
WA Health Surgical Safety Checklistbull Developed throughout 2010 bull Extensive stakeholder consultation and strong
agreement consensusbull Contains ALL components of C3 Protocolbull Modest changes and adaptation to WA contextbull Rolled out in November 2010bull Operational Directive OD 031611 March 2011
httpwwwhealthwagovaucircularsnewcircularcfmCirc_ID=12773
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Adapted From
WHO SSC Implementation Manual (2009)
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
WA Health Surgical Safety Checklist (cont)
bull Minimum standardbull Sites health services can ADD elements and
move elements between phasesbull 3-phase structure must be preservedbull Signature verification that all elements have
been verbally confirmed
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
WHO Checklist Adaptation Principles
bull Each section Focusedconcisebull Each section Brief (one min per section)bull Each item Actionablebull Designed for Verbal usebull Collaborative method of adaptionbull Tested in real situations before endorsementbull Integrated into routine processes
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Next StepshellipOSQH
bull Revise WA Correct PPS Policyndash Policy framework for the WA Checklist
bull Continued liaison w ACSQHC re checklists for other specialties
bull Evaluation of WA Checklist 2012ndash Auditndash Surveysndash Other data sources (AIMS HDMS)
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Next Stepshellipyou
bull Understand Checklist amp evidence bull Identify key people
ndash SampQndash Surgical nursing leads
bull Get involvedndash Auditndash Adaptndash Participation
bull Introduce
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Contact
For further information or feedback contact
Tel (08) 9222 4080 Fax (08) 9222 4324 E-mail safetyandqualityhealthwagovauWeb httpwwwsafetyandqualityhealthwagovau
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
References1 Haynes B et al A surgical safety checklist to reduce morbidity and mortality in a
global population New England Journal of Medicine 2009 360 491-92 Gawande A The Checklist Manifesto ndash How to get things right 2009
MacMillan Press3 Hales BM Pronovost PJ The checklist--a tool for error management and
performance improvement Journal of Critical Care 2006 21(3)231-54 Semel ME Resch S Haynes AB Funk LM Bader A Berry WR Weiser TG
Gawande AA Adopting a surgical safety checklist could save money and improve the quality of care in US hospitals Health Affairs 2010 29(9)1593-9
5 Haynes B et al Changes in safety attitude and relationships to decreased postoperative morbidity and mortality following implementation of a checklist- based surgical safety intervention BMJ Qual Safety 2011 20102-7
6 httpwwwwhointpatientsafetysafesurgerytools_resourcesenindexhtml
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Surgical Safety - Australian Response
2004 AHMC endorses the 5-step C3 Protocol
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
3 C Protocols
bull Developed by ACSQHC for other disciplinesndash General Radiologyndash Ultrasoundndash CT amp MRIndash Interventional Radiologyndash Nuclear Medicinendash Oral Surgeryndash Simulation Radiation Therapyndash Treatment Radiation Therapy
bull Four stage process
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
3 C Protocols conthellip
bull Four stage process1 Validation2 Matching3 Time out4 Post procedure
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Surgical Safety - Australian Response2004 AHMC endorses the 5-step C3 Protocol
2005 WA Correct PPS Policy 1st Ed
2006 Revised WA Correct PPS Policy
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Correct PPS Policy
Five Step Process1 Ensure that valid consent is
obtained2 Confirm the patientrsquos identity3 Mark the site of the surgery or
invasive procedure4 Take a final lsquoteam time outrsquo in the
operating theatre treatment or examination area
5 Ensure the correct and appropriate documents and diagnostic images are available
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Correct PPS Policy conthellip
bull Three stage process
1 Days to hours before procedure
2 Just before entering the operating theatre or treatment room
3 Immediately prior to the procedure
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Surgical Safety - Australian Response2004 AHMC endorses the 5-step C3 Protocol
2005 WA Correct PPS Policy 1st Ed
2006 Revised WA Correct PPS Policy
2008 National Compliance Audit C3 Protocolndash Variance amp deficits identified
2009 Local Compliance Audit (WA)ndash Variance amp deficits identified
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Correct PPS WA Audit Resultsbull Six hospital sites audited Oct 08 ndash Feb 09bull Considerable variance in compliance
ndash Obtaining valid consent (esp prior to administration of pre-surgery medication)
ndash Marking the surgical sitendash Final Team Time Out (esp verification of site marking
participation of anaesthetists)ndash Verification of documents amp diagnostic images
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Correct PPS WA Audit Resultsbull Six hospital sites audited Oct 08 ndash Feb 09bull Considerable variance in compliance
ndash Obtaining valid consent (esp prior to administration of pre-surgery medication)
ndash Marking the surgical sitendash Final Team Time Out (esp verification of site marking
participation of anaesthetists)ndash Verification of documents amp diagnostic images
RecommendationUpdate Correct PPS policy facilitate
implementation WHO Checklist
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Australian Response (cont)Nov 2009
ndash AHMC endorses the WHO Surgical Safety Checklist (Checklist) as agreed national strategy for surgical safety
ndash All jurisdictions to have implemented locally adapted versions by July 2011
Nov 2009ndash WA MDF endorses Checklist recommending that it be
implemented as minimum standard across WA Health
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
WHO Checklist Endorsementbull Royal Australasian College of Surgeonsbull Australian and New Zealand College of Anaesthetistsbull Royal Australian and New Zealand College of
Obstetricians and Gynaecologistsbull Royal Australian and New Zealand College of
Ophthalmologistsbull Australian College of Operating Room Nursesbull WA Medical Directorsrsquo Forum
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
WA Health Surgical Safety Checklistbull Developed throughout 2010 bull Extensive stakeholder consultation and strong
agreement consensusbull Contains ALL components of C3 Protocolbull Modest changes and adaptation to WA contextbull Rolled out in November 2010bull Operational Directive OD 031611 March 2011
httpwwwhealthwagovaucircularsnewcircularcfmCirc_ID=12773
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Adapted From
WHO SSC Implementation Manual (2009)
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
WA Health Surgical Safety Checklist (cont)
bull Minimum standardbull Sites health services can ADD elements and
move elements between phasesbull 3-phase structure must be preservedbull Signature verification that all elements have
been verbally confirmed
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
WHO Checklist Adaptation Principles
bull Each section Focusedconcisebull Each section Brief (one min per section)bull Each item Actionablebull Designed for Verbal usebull Collaborative method of adaptionbull Tested in real situations before endorsementbull Integrated into routine processes
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Next StepshellipOSQH
bull Revise WA Correct PPS Policyndash Policy framework for the WA Checklist
bull Continued liaison w ACSQHC re checklists for other specialties
bull Evaluation of WA Checklist 2012ndash Auditndash Surveysndash Other data sources (AIMS HDMS)
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Next Stepshellipyou
bull Understand Checklist amp evidence bull Identify key people
ndash SampQndash Surgical nursing leads
bull Get involvedndash Auditndash Adaptndash Participation
bull Introduce
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Contact
For further information or feedback contact
Tel (08) 9222 4080 Fax (08) 9222 4324 E-mail safetyandqualityhealthwagovauWeb httpwwwsafetyandqualityhealthwagovau
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
References1 Haynes B et al A surgical safety checklist to reduce morbidity and mortality in a
global population New England Journal of Medicine 2009 360 491-92 Gawande A The Checklist Manifesto ndash How to get things right 2009
MacMillan Press3 Hales BM Pronovost PJ The checklist--a tool for error management and
performance improvement Journal of Critical Care 2006 21(3)231-54 Semel ME Resch S Haynes AB Funk LM Bader A Berry WR Weiser TG
Gawande AA Adopting a surgical safety checklist could save money and improve the quality of care in US hospitals Health Affairs 2010 29(9)1593-9
5 Haynes B et al Changes in safety attitude and relationships to decreased postoperative morbidity and mortality following implementation of a checklist- based surgical safety intervention BMJ Qual Safety 2011 20102-7
6 httpwwwwhointpatientsafetysafesurgerytools_resourcesenindexhtml
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Surgical Safety - Australian Response
2004 AHMC endorses the 5-step C3 Protocol
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
3 C Protocols
bull Developed by ACSQHC for other disciplinesndash General Radiologyndash Ultrasoundndash CT amp MRIndash Interventional Radiologyndash Nuclear Medicinendash Oral Surgeryndash Simulation Radiation Therapyndash Treatment Radiation Therapy
bull Four stage process
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
3 C Protocols conthellip
bull Four stage process1 Validation2 Matching3 Time out4 Post procedure
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Surgical Safety - Australian Response2004 AHMC endorses the 5-step C3 Protocol
2005 WA Correct PPS Policy 1st Ed
2006 Revised WA Correct PPS Policy
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Correct PPS Policy
Five Step Process1 Ensure that valid consent is
obtained2 Confirm the patientrsquos identity3 Mark the site of the surgery or
invasive procedure4 Take a final lsquoteam time outrsquo in the
operating theatre treatment or examination area
5 Ensure the correct and appropriate documents and diagnostic images are available
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Correct PPS Policy conthellip
bull Three stage process
1 Days to hours before procedure
2 Just before entering the operating theatre or treatment room
3 Immediately prior to the procedure
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Surgical Safety - Australian Response2004 AHMC endorses the 5-step C3 Protocol
2005 WA Correct PPS Policy 1st Ed
2006 Revised WA Correct PPS Policy
2008 National Compliance Audit C3 Protocolndash Variance amp deficits identified
2009 Local Compliance Audit (WA)ndash Variance amp deficits identified
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Correct PPS WA Audit Resultsbull Six hospital sites audited Oct 08 ndash Feb 09bull Considerable variance in compliance
ndash Obtaining valid consent (esp prior to administration of pre-surgery medication)
ndash Marking the surgical sitendash Final Team Time Out (esp verification of site marking
participation of anaesthetists)ndash Verification of documents amp diagnostic images
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Correct PPS WA Audit Resultsbull Six hospital sites audited Oct 08 ndash Feb 09bull Considerable variance in compliance
ndash Obtaining valid consent (esp prior to administration of pre-surgery medication)
ndash Marking the surgical sitendash Final Team Time Out (esp verification of site marking
participation of anaesthetists)ndash Verification of documents amp diagnostic images
RecommendationUpdate Correct PPS policy facilitate
implementation WHO Checklist
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Australian Response (cont)Nov 2009
ndash AHMC endorses the WHO Surgical Safety Checklist (Checklist) as agreed national strategy for surgical safety
ndash All jurisdictions to have implemented locally adapted versions by July 2011
Nov 2009ndash WA MDF endorses Checklist recommending that it be
implemented as minimum standard across WA Health
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
WHO Checklist Endorsementbull Royal Australasian College of Surgeonsbull Australian and New Zealand College of Anaesthetistsbull Royal Australian and New Zealand College of
Obstetricians and Gynaecologistsbull Royal Australian and New Zealand College of
Ophthalmologistsbull Australian College of Operating Room Nursesbull WA Medical Directorsrsquo Forum
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
WA Health Surgical Safety Checklistbull Developed throughout 2010 bull Extensive stakeholder consultation and strong
agreement consensusbull Contains ALL components of C3 Protocolbull Modest changes and adaptation to WA contextbull Rolled out in November 2010bull Operational Directive OD 031611 March 2011
httpwwwhealthwagovaucircularsnewcircularcfmCirc_ID=12773
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Adapted From
WHO SSC Implementation Manual (2009)
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
WA Health Surgical Safety Checklist (cont)
bull Minimum standardbull Sites health services can ADD elements and
move elements between phasesbull 3-phase structure must be preservedbull Signature verification that all elements have
been verbally confirmed
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
WHO Checklist Adaptation Principles
bull Each section Focusedconcisebull Each section Brief (one min per section)bull Each item Actionablebull Designed for Verbal usebull Collaborative method of adaptionbull Tested in real situations before endorsementbull Integrated into routine processes
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Next StepshellipOSQH
bull Revise WA Correct PPS Policyndash Policy framework for the WA Checklist
bull Continued liaison w ACSQHC re checklists for other specialties
bull Evaluation of WA Checklist 2012ndash Auditndash Surveysndash Other data sources (AIMS HDMS)
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Next Stepshellipyou
bull Understand Checklist amp evidence bull Identify key people
ndash SampQndash Surgical nursing leads
bull Get involvedndash Auditndash Adaptndash Participation
bull Introduce
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Contact
For further information or feedback contact
Tel (08) 9222 4080 Fax (08) 9222 4324 E-mail safetyandqualityhealthwagovauWeb httpwwwsafetyandqualityhealthwagovau
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
References1 Haynes B et al A surgical safety checklist to reduce morbidity and mortality in a
global population New England Journal of Medicine 2009 360 491-92 Gawande A The Checklist Manifesto ndash How to get things right 2009
MacMillan Press3 Hales BM Pronovost PJ The checklist--a tool for error management and
performance improvement Journal of Critical Care 2006 21(3)231-54 Semel ME Resch S Haynes AB Funk LM Bader A Berry WR Weiser TG
Gawande AA Adopting a surgical safety checklist could save money and improve the quality of care in US hospitals Health Affairs 2010 29(9)1593-9
5 Haynes B et al Changes in safety attitude and relationships to decreased postoperative morbidity and mortality following implementation of a checklist- based surgical safety intervention BMJ Qual Safety 2011 20102-7
6 httpwwwwhointpatientsafetysafesurgerytools_resourcesenindexhtml
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Surgical Safety - Australian Response
2004 AHMC endorses the 5-step C3 Protocol
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
3 C Protocols
bull Developed by ACSQHC for other disciplinesndash General Radiologyndash Ultrasoundndash CT amp MRIndash Interventional Radiologyndash Nuclear Medicinendash Oral Surgeryndash Simulation Radiation Therapyndash Treatment Radiation Therapy
bull Four stage process
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
3 C Protocols conthellip
bull Four stage process1 Validation2 Matching3 Time out4 Post procedure
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Surgical Safety - Australian Response2004 AHMC endorses the 5-step C3 Protocol
2005 WA Correct PPS Policy 1st Ed
2006 Revised WA Correct PPS Policy
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Correct PPS Policy
Five Step Process1 Ensure that valid consent is
obtained2 Confirm the patientrsquos identity3 Mark the site of the surgery or
invasive procedure4 Take a final lsquoteam time outrsquo in the
operating theatre treatment or examination area
5 Ensure the correct and appropriate documents and diagnostic images are available
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Correct PPS Policy conthellip
bull Three stage process
1 Days to hours before procedure
2 Just before entering the operating theatre or treatment room
3 Immediately prior to the procedure
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Surgical Safety - Australian Response2004 AHMC endorses the 5-step C3 Protocol
2005 WA Correct PPS Policy 1st Ed
2006 Revised WA Correct PPS Policy
2008 National Compliance Audit C3 Protocolndash Variance amp deficits identified
2009 Local Compliance Audit (WA)ndash Variance amp deficits identified
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Correct PPS WA Audit Resultsbull Six hospital sites audited Oct 08 ndash Feb 09bull Considerable variance in compliance
ndash Obtaining valid consent (esp prior to administration of pre-surgery medication)
ndash Marking the surgical sitendash Final Team Time Out (esp verification of site marking
participation of anaesthetists)ndash Verification of documents amp diagnostic images
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Correct PPS WA Audit Resultsbull Six hospital sites audited Oct 08 ndash Feb 09bull Considerable variance in compliance
ndash Obtaining valid consent (esp prior to administration of pre-surgery medication)
ndash Marking the surgical sitendash Final Team Time Out (esp verification of site marking
participation of anaesthetists)ndash Verification of documents amp diagnostic images
RecommendationUpdate Correct PPS policy facilitate
implementation WHO Checklist
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Australian Response (cont)Nov 2009
ndash AHMC endorses the WHO Surgical Safety Checklist (Checklist) as agreed national strategy for surgical safety
ndash All jurisdictions to have implemented locally adapted versions by July 2011
Nov 2009ndash WA MDF endorses Checklist recommending that it be
implemented as minimum standard across WA Health
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
WHO Checklist Endorsementbull Royal Australasian College of Surgeonsbull Australian and New Zealand College of Anaesthetistsbull Royal Australian and New Zealand College of
Obstetricians and Gynaecologistsbull Royal Australian and New Zealand College of
Ophthalmologistsbull Australian College of Operating Room Nursesbull WA Medical Directorsrsquo Forum
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
WA Health Surgical Safety Checklistbull Developed throughout 2010 bull Extensive stakeholder consultation and strong
agreement consensusbull Contains ALL components of C3 Protocolbull Modest changes and adaptation to WA contextbull Rolled out in November 2010bull Operational Directive OD 031611 March 2011
httpwwwhealthwagovaucircularsnewcircularcfmCirc_ID=12773
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Adapted From
WHO SSC Implementation Manual (2009)
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
WA Health Surgical Safety Checklist (cont)
bull Minimum standardbull Sites health services can ADD elements and
move elements between phasesbull 3-phase structure must be preservedbull Signature verification that all elements have
been verbally confirmed
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
WHO Checklist Adaptation Principles
bull Each section Focusedconcisebull Each section Brief (one min per section)bull Each item Actionablebull Designed for Verbal usebull Collaborative method of adaptionbull Tested in real situations before endorsementbull Integrated into routine processes
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Next StepshellipOSQH
bull Revise WA Correct PPS Policyndash Policy framework for the WA Checklist
bull Continued liaison w ACSQHC re checklists for other specialties
bull Evaluation of WA Checklist 2012ndash Auditndash Surveysndash Other data sources (AIMS HDMS)
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Next Stepshellipyou
bull Understand Checklist amp evidence bull Identify key people
ndash SampQndash Surgical nursing leads
bull Get involvedndash Auditndash Adaptndash Participation
bull Introduce
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Contact
For further information or feedback contact
Tel (08) 9222 4080 Fax (08) 9222 4324 E-mail safetyandqualityhealthwagovauWeb httpwwwsafetyandqualityhealthwagovau
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
References1 Haynes B et al A surgical safety checklist to reduce morbidity and mortality in a
global population New England Journal of Medicine 2009 360 491-92 Gawande A The Checklist Manifesto ndash How to get things right 2009
MacMillan Press3 Hales BM Pronovost PJ The checklist--a tool for error management and
performance improvement Journal of Critical Care 2006 21(3)231-54 Semel ME Resch S Haynes AB Funk LM Bader A Berry WR Weiser TG
Gawande AA Adopting a surgical safety checklist could save money and improve the quality of care in US hospitals Health Affairs 2010 29(9)1593-9
5 Haynes B et al Changes in safety attitude and relationships to decreased postoperative morbidity and mortality following implementation of a checklist- based surgical safety intervention BMJ Qual Safety 2011 20102-7
6 httpwwwwhointpatientsafetysafesurgerytools_resourcesenindexhtml
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Surgical Safety - Australian Response
2004 AHMC endorses the 5-step C3 Protocol
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
3 C Protocols
bull Developed by ACSQHC for other disciplinesndash General Radiologyndash Ultrasoundndash CT amp MRIndash Interventional Radiologyndash Nuclear Medicinendash Oral Surgeryndash Simulation Radiation Therapyndash Treatment Radiation Therapy
bull Four stage process
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
3 C Protocols conthellip
bull Four stage process1 Validation2 Matching3 Time out4 Post procedure
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Surgical Safety - Australian Response2004 AHMC endorses the 5-step C3 Protocol
2005 WA Correct PPS Policy 1st Ed
2006 Revised WA Correct PPS Policy
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Correct PPS Policy
Five Step Process1 Ensure that valid consent is
obtained2 Confirm the patientrsquos identity3 Mark the site of the surgery or
invasive procedure4 Take a final lsquoteam time outrsquo in the
operating theatre treatment or examination area
5 Ensure the correct and appropriate documents and diagnostic images are available
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Correct PPS Policy conthellip
bull Three stage process
1 Days to hours before procedure
2 Just before entering the operating theatre or treatment room
3 Immediately prior to the procedure
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Surgical Safety - Australian Response2004 AHMC endorses the 5-step C3 Protocol
2005 WA Correct PPS Policy 1st Ed
2006 Revised WA Correct PPS Policy
2008 National Compliance Audit C3 Protocolndash Variance amp deficits identified
2009 Local Compliance Audit (WA)ndash Variance amp deficits identified
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Correct PPS WA Audit Resultsbull Six hospital sites audited Oct 08 ndash Feb 09bull Considerable variance in compliance
ndash Obtaining valid consent (esp prior to administration of pre-surgery medication)
ndash Marking the surgical sitendash Final Team Time Out (esp verification of site marking
participation of anaesthetists)ndash Verification of documents amp diagnostic images
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Correct PPS WA Audit Resultsbull Six hospital sites audited Oct 08 ndash Feb 09bull Considerable variance in compliance
ndash Obtaining valid consent (esp prior to administration of pre-surgery medication)
ndash Marking the surgical sitendash Final Team Time Out (esp verification of site marking
participation of anaesthetists)ndash Verification of documents amp diagnostic images
RecommendationUpdate Correct PPS policy facilitate
implementation WHO Checklist
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Australian Response (cont)Nov 2009
ndash AHMC endorses the WHO Surgical Safety Checklist (Checklist) as agreed national strategy for surgical safety
ndash All jurisdictions to have implemented locally adapted versions by July 2011
Nov 2009ndash WA MDF endorses Checklist recommending that it be
implemented as minimum standard across WA Health
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
WHO Checklist Endorsementbull Royal Australasian College of Surgeonsbull Australian and New Zealand College of Anaesthetistsbull Royal Australian and New Zealand College of
Obstetricians and Gynaecologistsbull Royal Australian and New Zealand College of
Ophthalmologistsbull Australian College of Operating Room Nursesbull WA Medical Directorsrsquo Forum
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
WA Health Surgical Safety Checklistbull Developed throughout 2010 bull Extensive stakeholder consultation and strong
agreement consensusbull Contains ALL components of C3 Protocolbull Modest changes and adaptation to WA contextbull Rolled out in November 2010bull Operational Directive OD 031611 March 2011
httpwwwhealthwagovaucircularsnewcircularcfmCirc_ID=12773
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Adapted From
WHO SSC Implementation Manual (2009)
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
WA Health Surgical Safety Checklist (cont)
bull Minimum standardbull Sites health services can ADD elements and
move elements between phasesbull 3-phase structure must be preservedbull Signature verification that all elements have
been verbally confirmed
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
WHO Checklist Adaptation Principles
bull Each section Focusedconcisebull Each section Brief (one min per section)bull Each item Actionablebull Designed for Verbal usebull Collaborative method of adaptionbull Tested in real situations before endorsementbull Integrated into routine processes
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Next StepshellipOSQH
bull Revise WA Correct PPS Policyndash Policy framework for the WA Checklist
bull Continued liaison w ACSQHC re checklists for other specialties
bull Evaluation of WA Checklist 2012ndash Auditndash Surveysndash Other data sources (AIMS HDMS)
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Next Stepshellipyou
bull Understand Checklist amp evidence bull Identify key people
ndash SampQndash Surgical nursing leads
bull Get involvedndash Auditndash Adaptndash Participation
bull Introduce
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Contact
For further information or feedback contact
Tel (08) 9222 4080 Fax (08) 9222 4324 E-mail safetyandqualityhealthwagovauWeb httpwwwsafetyandqualityhealthwagovau
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
References1 Haynes B et al A surgical safety checklist to reduce morbidity and mortality in a
global population New England Journal of Medicine 2009 360 491-92 Gawande A The Checklist Manifesto ndash How to get things right 2009
MacMillan Press3 Hales BM Pronovost PJ The checklist--a tool for error management and
performance improvement Journal of Critical Care 2006 21(3)231-54 Semel ME Resch S Haynes AB Funk LM Bader A Berry WR Weiser TG
Gawande AA Adopting a surgical safety checklist could save money and improve the quality of care in US hospitals Health Affairs 2010 29(9)1593-9
5 Haynes B et al Changes in safety attitude and relationships to decreased postoperative morbidity and mortality following implementation of a checklist- based surgical safety intervention BMJ Qual Safety 2011 20102-7
6 httpwwwwhointpatientsafetysafesurgerytools_resourcesenindexhtml
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Surgical Safety - Australian Response
2004 AHMC endorses the 5-step C3 Protocol
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
3 C Protocols
bull Developed by ACSQHC for other disciplinesndash General Radiologyndash Ultrasoundndash CT amp MRIndash Interventional Radiologyndash Nuclear Medicinendash Oral Surgeryndash Simulation Radiation Therapyndash Treatment Radiation Therapy
bull Four stage process
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
3 C Protocols conthellip
bull Four stage process1 Validation2 Matching3 Time out4 Post procedure
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Surgical Safety - Australian Response2004 AHMC endorses the 5-step C3 Protocol
2005 WA Correct PPS Policy 1st Ed
2006 Revised WA Correct PPS Policy
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Correct PPS Policy
Five Step Process1 Ensure that valid consent is
obtained2 Confirm the patientrsquos identity3 Mark the site of the surgery or
invasive procedure4 Take a final lsquoteam time outrsquo in the
operating theatre treatment or examination area
5 Ensure the correct and appropriate documents and diagnostic images are available
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Correct PPS Policy conthellip
bull Three stage process
1 Days to hours before procedure
2 Just before entering the operating theatre or treatment room
3 Immediately prior to the procedure
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Surgical Safety - Australian Response2004 AHMC endorses the 5-step C3 Protocol
2005 WA Correct PPS Policy 1st Ed
2006 Revised WA Correct PPS Policy
2008 National Compliance Audit C3 Protocolndash Variance amp deficits identified
2009 Local Compliance Audit (WA)ndash Variance amp deficits identified
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Correct PPS WA Audit Resultsbull Six hospital sites audited Oct 08 ndash Feb 09bull Considerable variance in compliance
ndash Obtaining valid consent (esp prior to administration of pre-surgery medication)
ndash Marking the surgical sitendash Final Team Time Out (esp verification of site marking
participation of anaesthetists)ndash Verification of documents amp diagnostic images
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Correct PPS WA Audit Resultsbull Six hospital sites audited Oct 08 ndash Feb 09bull Considerable variance in compliance
ndash Obtaining valid consent (esp prior to administration of pre-surgery medication)
ndash Marking the surgical sitendash Final Team Time Out (esp verification of site marking
participation of anaesthetists)ndash Verification of documents amp diagnostic images
RecommendationUpdate Correct PPS policy facilitate
implementation WHO Checklist
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Australian Response (cont)Nov 2009
ndash AHMC endorses the WHO Surgical Safety Checklist (Checklist) as agreed national strategy for surgical safety
ndash All jurisdictions to have implemented locally adapted versions by July 2011
Nov 2009ndash WA MDF endorses Checklist recommending that it be
implemented as minimum standard across WA Health
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
WHO Checklist Endorsementbull Royal Australasian College of Surgeonsbull Australian and New Zealand College of Anaesthetistsbull Royal Australian and New Zealand College of
Obstetricians and Gynaecologistsbull Royal Australian and New Zealand College of
Ophthalmologistsbull Australian College of Operating Room Nursesbull WA Medical Directorsrsquo Forum
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
WA Health Surgical Safety Checklistbull Developed throughout 2010 bull Extensive stakeholder consultation and strong
agreement consensusbull Contains ALL components of C3 Protocolbull Modest changes and adaptation to WA contextbull Rolled out in November 2010bull Operational Directive OD 031611 March 2011
httpwwwhealthwagovaucircularsnewcircularcfmCirc_ID=12773
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Adapted From
WHO SSC Implementation Manual (2009)
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
WA Health Surgical Safety Checklist (cont)
bull Minimum standardbull Sites health services can ADD elements and
move elements between phasesbull 3-phase structure must be preservedbull Signature verification that all elements have
been verbally confirmed
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
WHO Checklist Adaptation Principles
bull Each section Focusedconcisebull Each section Brief (one min per section)bull Each item Actionablebull Designed for Verbal usebull Collaborative method of adaptionbull Tested in real situations before endorsementbull Integrated into routine processes
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Next StepshellipOSQH
bull Revise WA Correct PPS Policyndash Policy framework for the WA Checklist
bull Continued liaison w ACSQHC re checklists for other specialties
bull Evaluation of WA Checklist 2012ndash Auditndash Surveysndash Other data sources (AIMS HDMS)
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Next Stepshellipyou
bull Understand Checklist amp evidence bull Identify key people
ndash SampQndash Surgical nursing leads
bull Get involvedndash Auditndash Adaptndash Participation
bull Introduce
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Contact
For further information or feedback contact
Tel (08) 9222 4080 Fax (08) 9222 4324 E-mail safetyandqualityhealthwagovauWeb httpwwwsafetyandqualityhealthwagovau
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
References1 Haynes B et al A surgical safety checklist to reduce morbidity and mortality in a
global population New England Journal of Medicine 2009 360 491-92 Gawande A The Checklist Manifesto ndash How to get things right 2009
MacMillan Press3 Hales BM Pronovost PJ The checklist--a tool for error management and
performance improvement Journal of Critical Care 2006 21(3)231-54 Semel ME Resch S Haynes AB Funk LM Bader A Berry WR Weiser TG
Gawande AA Adopting a surgical safety checklist could save money and improve the quality of care in US hospitals Health Affairs 2010 29(9)1593-9
5 Haynes B et al Changes in safety attitude and relationships to decreased postoperative morbidity and mortality following implementation of a checklist- based surgical safety intervention BMJ Qual Safety 2011 20102-7
6 httpwwwwhointpatientsafetysafesurgerytools_resourcesenindexhtml
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
3 C Protocols
bull Developed by ACSQHC for other disciplinesndash General Radiologyndash Ultrasoundndash CT amp MRIndash Interventional Radiologyndash Nuclear Medicinendash Oral Surgeryndash Simulation Radiation Therapyndash Treatment Radiation Therapy
bull Four stage process
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
3 C Protocols conthellip
bull Four stage process1 Validation2 Matching3 Time out4 Post procedure
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Surgical Safety - Australian Response2004 AHMC endorses the 5-step C3 Protocol
2005 WA Correct PPS Policy 1st Ed
2006 Revised WA Correct PPS Policy
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Correct PPS Policy
Five Step Process1 Ensure that valid consent is
obtained2 Confirm the patientrsquos identity3 Mark the site of the surgery or
invasive procedure4 Take a final lsquoteam time outrsquo in the
operating theatre treatment or examination area
5 Ensure the correct and appropriate documents and diagnostic images are available
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Correct PPS Policy conthellip
bull Three stage process
1 Days to hours before procedure
2 Just before entering the operating theatre or treatment room
3 Immediately prior to the procedure
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Surgical Safety - Australian Response2004 AHMC endorses the 5-step C3 Protocol
2005 WA Correct PPS Policy 1st Ed
2006 Revised WA Correct PPS Policy
2008 National Compliance Audit C3 Protocolndash Variance amp deficits identified
2009 Local Compliance Audit (WA)ndash Variance amp deficits identified
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Correct PPS WA Audit Resultsbull Six hospital sites audited Oct 08 ndash Feb 09bull Considerable variance in compliance
ndash Obtaining valid consent (esp prior to administration of pre-surgery medication)
ndash Marking the surgical sitendash Final Team Time Out (esp verification of site marking
participation of anaesthetists)ndash Verification of documents amp diagnostic images
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Correct PPS WA Audit Resultsbull Six hospital sites audited Oct 08 ndash Feb 09bull Considerable variance in compliance
ndash Obtaining valid consent (esp prior to administration of pre-surgery medication)
ndash Marking the surgical sitendash Final Team Time Out (esp verification of site marking
participation of anaesthetists)ndash Verification of documents amp diagnostic images
RecommendationUpdate Correct PPS policy facilitate
implementation WHO Checklist
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Australian Response (cont)Nov 2009
ndash AHMC endorses the WHO Surgical Safety Checklist (Checklist) as agreed national strategy for surgical safety
ndash All jurisdictions to have implemented locally adapted versions by July 2011
Nov 2009ndash WA MDF endorses Checklist recommending that it be
implemented as minimum standard across WA Health
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
WHO Checklist Endorsementbull Royal Australasian College of Surgeonsbull Australian and New Zealand College of Anaesthetistsbull Royal Australian and New Zealand College of
Obstetricians and Gynaecologistsbull Royal Australian and New Zealand College of
Ophthalmologistsbull Australian College of Operating Room Nursesbull WA Medical Directorsrsquo Forum
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
WA Health Surgical Safety Checklistbull Developed throughout 2010 bull Extensive stakeholder consultation and strong
agreement consensusbull Contains ALL components of C3 Protocolbull Modest changes and adaptation to WA contextbull Rolled out in November 2010bull Operational Directive OD 031611 March 2011
httpwwwhealthwagovaucircularsnewcircularcfmCirc_ID=12773
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Adapted From
WHO SSC Implementation Manual (2009)
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
WA Health Surgical Safety Checklist (cont)
bull Minimum standardbull Sites health services can ADD elements and
move elements between phasesbull 3-phase structure must be preservedbull Signature verification that all elements have
been verbally confirmed
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
WHO Checklist Adaptation Principles
bull Each section Focusedconcisebull Each section Brief (one min per section)bull Each item Actionablebull Designed for Verbal usebull Collaborative method of adaptionbull Tested in real situations before endorsementbull Integrated into routine processes
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Next StepshellipOSQH
bull Revise WA Correct PPS Policyndash Policy framework for the WA Checklist
bull Continued liaison w ACSQHC re checklists for other specialties
bull Evaluation of WA Checklist 2012ndash Auditndash Surveysndash Other data sources (AIMS HDMS)
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Next Stepshellipyou
bull Understand Checklist amp evidence bull Identify key people
ndash SampQndash Surgical nursing leads
bull Get involvedndash Auditndash Adaptndash Participation
bull Introduce
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Contact
For further information or feedback contact
Tel (08) 9222 4080 Fax (08) 9222 4324 E-mail safetyandqualityhealthwagovauWeb httpwwwsafetyandqualityhealthwagovau
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
References1 Haynes B et al A surgical safety checklist to reduce morbidity and mortality in a
global population New England Journal of Medicine 2009 360 491-92 Gawande A The Checklist Manifesto ndash How to get things right 2009
MacMillan Press3 Hales BM Pronovost PJ The checklist--a tool for error management and
performance improvement Journal of Critical Care 2006 21(3)231-54 Semel ME Resch S Haynes AB Funk LM Bader A Berry WR Weiser TG
Gawande AA Adopting a surgical safety checklist could save money and improve the quality of care in US hospitals Health Affairs 2010 29(9)1593-9
5 Haynes B et al Changes in safety attitude and relationships to decreased postoperative morbidity and mortality following implementation of a checklist- based surgical safety intervention BMJ Qual Safety 2011 20102-7
6 httpwwwwhointpatientsafetysafesurgerytools_resourcesenindexhtml
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
3 C Protocols conthellip
bull Four stage process1 Validation2 Matching3 Time out4 Post procedure
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Surgical Safety - Australian Response2004 AHMC endorses the 5-step C3 Protocol
2005 WA Correct PPS Policy 1st Ed
2006 Revised WA Correct PPS Policy
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Correct PPS Policy
Five Step Process1 Ensure that valid consent is
obtained2 Confirm the patientrsquos identity3 Mark the site of the surgery or
invasive procedure4 Take a final lsquoteam time outrsquo in the
operating theatre treatment or examination area
5 Ensure the correct and appropriate documents and diagnostic images are available
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Correct PPS Policy conthellip
bull Three stage process
1 Days to hours before procedure
2 Just before entering the operating theatre or treatment room
3 Immediately prior to the procedure
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Surgical Safety - Australian Response2004 AHMC endorses the 5-step C3 Protocol
2005 WA Correct PPS Policy 1st Ed
2006 Revised WA Correct PPS Policy
2008 National Compliance Audit C3 Protocolndash Variance amp deficits identified
2009 Local Compliance Audit (WA)ndash Variance amp deficits identified
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Correct PPS WA Audit Resultsbull Six hospital sites audited Oct 08 ndash Feb 09bull Considerable variance in compliance
ndash Obtaining valid consent (esp prior to administration of pre-surgery medication)
ndash Marking the surgical sitendash Final Team Time Out (esp verification of site marking
participation of anaesthetists)ndash Verification of documents amp diagnostic images
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Correct PPS WA Audit Resultsbull Six hospital sites audited Oct 08 ndash Feb 09bull Considerable variance in compliance
ndash Obtaining valid consent (esp prior to administration of pre-surgery medication)
ndash Marking the surgical sitendash Final Team Time Out (esp verification of site marking
participation of anaesthetists)ndash Verification of documents amp diagnostic images
RecommendationUpdate Correct PPS policy facilitate
implementation WHO Checklist
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Australian Response (cont)Nov 2009
ndash AHMC endorses the WHO Surgical Safety Checklist (Checklist) as agreed national strategy for surgical safety
ndash All jurisdictions to have implemented locally adapted versions by July 2011
Nov 2009ndash WA MDF endorses Checklist recommending that it be
implemented as minimum standard across WA Health
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
WHO Checklist Endorsementbull Royal Australasian College of Surgeonsbull Australian and New Zealand College of Anaesthetistsbull Royal Australian and New Zealand College of
Obstetricians and Gynaecologistsbull Royal Australian and New Zealand College of
Ophthalmologistsbull Australian College of Operating Room Nursesbull WA Medical Directorsrsquo Forum
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
WA Health Surgical Safety Checklistbull Developed throughout 2010 bull Extensive stakeholder consultation and strong
agreement consensusbull Contains ALL components of C3 Protocolbull Modest changes and adaptation to WA contextbull Rolled out in November 2010bull Operational Directive OD 031611 March 2011
httpwwwhealthwagovaucircularsnewcircularcfmCirc_ID=12773
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Adapted From
WHO SSC Implementation Manual (2009)
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
WA Health Surgical Safety Checklist (cont)
bull Minimum standardbull Sites health services can ADD elements and
move elements between phasesbull 3-phase structure must be preservedbull Signature verification that all elements have
been verbally confirmed
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
WHO Checklist Adaptation Principles
bull Each section Focusedconcisebull Each section Brief (one min per section)bull Each item Actionablebull Designed for Verbal usebull Collaborative method of adaptionbull Tested in real situations before endorsementbull Integrated into routine processes
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Next StepshellipOSQH
bull Revise WA Correct PPS Policyndash Policy framework for the WA Checklist
bull Continued liaison w ACSQHC re checklists for other specialties
bull Evaluation of WA Checklist 2012ndash Auditndash Surveysndash Other data sources (AIMS HDMS)
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Next Stepshellipyou
bull Understand Checklist amp evidence bull Identify key people
ndash SampQndash Surgical nursing leads
bull Get involvedndash Auditndash Adaptndash Participation
bull Introduce
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Contact
For further information or feedback contact
Tel (08) 9222 4080 Fax (08) 9222 4324 E-mail safetyandqualityhealthwagovauWeb httpwwwsafetyandqualityhealthwagovau
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
References1 Haynes B et al A surgical safety checklist to reduce morbidity and mortality in a
global population New England Journal of Medicine 2009 360 491-92 Gawande A The Checklist Manifesto ndash How to get things right 2009
MacMillan Press3 Hales BM Pronovost PJ The checklist--a tool for error management and
performance improvement Journal of Critical Care 2006 21(3)231-54 Semel ME Resch S Haynes AB Funk LM Bader A Berry WR Weiser TG
Gawande AA Adopting a surgical safety checklist could save money and improve the quality of care in US hospitals Health Affairs 2010 29(9)1593-9
5 Haynes B et al Changes in safety attitude and relationships to decreased postoperative morbidity and mortality following implementation of a checklist- based surgical safety intervention BMJ Qual Safety 2011 20102-7
6 httpwwwwhointpatientsafetysafesurgerytools_resourcesenindexhtml
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Surgical Safety - Australian Response2004 AHMC endorses the 5-step C3 Protocol
2005 WA Correct PPS Policy 1st Ed
2006 Revised WA Correct PPS Policy
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Correct PPS Policy
Five Step Process1 Ensure that valid consent is
obtained2 Confirm the patientrsquos identity3 Mark the site of the surgery or
invasive procedure4 Take a final lsquoteam time outrsquo in the
operating theatre treatment or examination area
5 Ensure the correct and appropriate documents and diagnostic images are available
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Correct PPS Policy conthellip
bull Three stage process
1 Days to hours before procedure
2 Just before entering the operating theatre or treatment room
3 Immediately prior to the procedure
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Surgical Safety - Australian Response2004 AHMC endorses the 5-step C3 Protocol
2005 WA Correct PPS Policy 1st Ed
2006 Revised WA Correct PPS Policy
2008 National Compliance Audit C3 Protocolndash Variance amp deficits identified
2009 Local Compliance Audit (WA)ndash Variance amp deficits identified
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Correct PPS WA Audit Resultsbull Six hospital sites audited Oct 08 ndash Feb 09bull Considerable variance in compliance
ndash Obtaining valid consent (esp prior to administration of pre-surgery medication)
ndash Marking the surgical sitendash Final Team Time Out (esp verification of site marking
participation of anaesthetists)ndash Verification of documents amp diagnostic images
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Correct PPS WA Audit Resultsbull Six hospital sites audited Oct 08 ndash Feb 09bull Considerable variance in compliance
ndash Obtaining valid consent (esp prior to administration of pre-surgery medication)
ndash Marking the surgical sitendash Final Team Time Out (esp verification of site marking
participation of anaesthetists)ndash Verification of documents amp diagnostic images
RecommendationUpdate Correct PPS policy facilitate
implementation WHO Checklist
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Australian Response (cont)Nov 2009
ndash AHMC endorses the WHO Surgical Safety Checklist (Checklist) as agreed national strategy for surgical safety
ndash All jurisdictions to have implemented locally adapted versions by July 2011
Nov 2009ndash WA MDF endorses Checklist recommending that it be
implemented as minimum standard across WA Health
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
WHO Checklist Endorsementbull Royal Australasian College of Surgeonsbull Australian and New Zealand College of Anaesthetistsbull Royal Australian and New Zealand College of
Obstetricians and Gynaecologistsbull Royal Australian and New Zealand College of
Ophthalmologistsbull Australian College of Operating Room Nursesbull WA Medical Directorsrsquo Forum
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
WA Health Surgical Safety Checklistbull Developed throughout 2010 bull Extensive stakeholder consultation and strong
agreement consensusbull Contains ALL components of C3 Protocolbull Modest changes and adaptation to WA contextbull Rolled out in November 2010bull Operational Directive OD 031611 March 2011
httpwwwhealthwagovaucircularsnewcircularcfmCirc_ID=12773
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Adapted From
WHO SSC Implementation Manual (2009)
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
WA Health Surgical Safety Checklist (cont)
bull Minimum standardbull Sites health services can ADD elements and
move elements between phasesbull 3-phase structure must be preservedbull Signature verification that all elements have
been verbally confirmed
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
WHO Checklist Adaptation Principles
bull Each section Focusedconcisebull Each section Brief (one min per section)bull Each item Actionablebull Designed for Verbal usebull Collaborative method of adaptionbull Tested in real situations before endorsementbull Integrated into routine processes
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Next StepshellipOSQH
bull Revise WA Correct PPS Policyndash Policy framework for the WA Checklist
bull Continued liaison w ACSQHC re checklists for other specialties
bull Evaluation of WA Checklist 2012ndash Auditndash Surveysndash Other data sources (AIMS HDMS)
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Next Stepshellipyou
bull Understand Checklist amp evidence bull Identify key people
ndash SampQndash Surgical nursing leads
bull Get involvedndash Auditndash Adaptndash Participation
bull Introduce
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Contact
For further information or feedback contact
Tel (08) 9222 4080 Fax (08) 9222 4324 E-mail safetyandqualityhealthwagovauWeb httpwwwsafetyandqualityhealthwagovau
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
References1 Haynes B et al A surgical safety checklist to reduce morbidity and mortality in a
global population New England Journal of Medicine 2009 360 491-92 Gawande A The Checklist Manifesto ndash How to get things right 2009
MacMillan Press3 Hales BM Pronovost PJ The checklist--a tool for error management and
performance improvement Journal of Critical Care 2006 21(3)231-54 Semel ME Resch S Haynes AB Funk LM Bader A Berry WR Weiser TG
Gawande AA Adopting a surgical safety checklist could save money and improve the quality of care in US hospitals Health Affairs 2010 29(9)1593-9
5 Haynes B et al Changes in safety attitude and relationships to decreased postoperative morbidity and mortality following implementation of a checklist- based surgical safety intervention BMJ Qual Safety 2011 20102-7
6 httpwwwwhointpatientsafetysafesurgerytools_resourcesenindexhtml
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Correct PPS Policy
Five Step Process1 Ensure that valid consent is
obtained2 Confirm the patientrsquos identity3 Mark the site of the surgery or
invasive procedure4 Take a final lsquoteam time outrsquo in the
operating theatre treatment or examination area
5 Ensure the correct and appropriate documents and diagnostic images are available
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Correct PPS Policy conthellip
bull Three stage process
1 Days to hours before procedure
2 Just before entering the operating theatre or treatment room
3 Immediately prior to the procedure
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Surgical Safety - Australian Response2004 AHMC endorses the 5-step C3 Protocol
2005 WA Correct PPS Policy 1st Ed
2006 Revised WA Correct PPS Policy
2008 National Compliance Audit C3 Protocolndash Variance amp deficits identified
2009 Local Compliance Audit (WA)ndash Variance amp deficits identified
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Correct PPS WA Audit Resultsbull Six hospital sites audited Oct 08 ndash Feb 09bull Considerable variance in compliance
ndash Obtaining valid consent (esp prior to administration of pre-surgery medication)
ndash Marking the surgical sitendash Final Team Time Out (esp verification of site marking
participation of anaesthetists)ndash Verification of documents amp diagnostic images
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Correct PPS WA Audit Resultsbull Six hospital sites audited Oct 08 ndash Feb 09bull Considerable variance in compliance
ndash Obtaining valid consent (esp prior to administration of pre-surgery medication)
ndash Marking the surgical sitendash Final Team Time Out (esp verification of site marking
participation of anaesthetists)ndash Verification of documents amp diagnostic images
RecommendationUpdate Correct PPS policy facilitate
implementation WHO Checklist
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Australian Response (cont)Nov 2009
ndash AHMC endorses the WHO Surgical Safety Checklist (Checklist) as agreed national strategy for surgical safety
ndash All jurisdictions to have implemented locally adapted versions by July 2011
Nov 2009ndash WA MDF endorses Checklist recommending that it be
implemented as minimum standard across WA Health
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
WHO Checklist Endorsementbull Royal Australasian College of Surgeonsbull Australian and New Zealand College of Anaesthetistsbull Royal Australian and New Zealand College of
Obstetricians and Gynaecologistsbull Royal Australian and New Zealand College of
Ophthalmologistsbull Australian College of Operating Room Nursesbull WA Medical Directorsrsquo Forum
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
WA Health Surgical Safety Checklistbull Developed throughout 2010 bull Extensive stakeholder consultation and strong
agreement consensusbull Contains ALL components of C3 Protocolbull Modest changes and adaptation to WA contextbull Rolled out in November 2010bull Operational Directive OD 031611 March 2011
httpwwwhealthwagovaucircularsnewcircularcfmCirc_ID=12773
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Adapted From
WHO SSC Implementation Manual (2009)
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
WA Health Surgical Safety Checklist (cont)
bull Minimum standardbull Sites health services can ADD elements and
move elements between phasesbull 3-phase structure must be preservedbull Signature verification that all elements have
been verbally confirmed
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
WHO Checklist Adaptation Principles
bull Each section Focusedconcisebull Each section Brief (one min per section)bull Each item Actionablebull Designed for Verbal usebull Collaborative method of adaptionbull Tested in real situations before endorsementbull Integrated into routine processes
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Next StepshellipOSQH
bull Revise WA Correct PPS Policyndash Policy framework for the WA Checklist
bull Continued liaison w ACSQHC re checklists for other specialties
bull Evaluation of WA Checklist 2012ndash Auditndash Surveysndash Other data sources (AIMS HDMS)
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Next Stepshellipyou
bull Understand Checklist amp evidence bull Identify key people
ndash SampQndash Surgical nursing leads
bull Get involvedndash Auditndash Adaptndash Participation
bull Introduce
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Contact
For further information or feedback contact
Tel (08) 9222 4080 Fax (08) 9222 4324 E-mail safetyandqualityhealthwagovauWeb httpwwwsafetyandqualityhealthwagovau
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
References1 Haynes B et al A surgical safety checklist to reduce morbidity and mortality in a
global population New England Journal of Medicine 2009 360 491-92 Gawande A The Checklist Manifesto ndash How to get things right 2009
MacMillan Press3 Hales BM Pronovost PJ The checklist--a tool for error management and
performance improvement Journal of Critical Care 2006 21(3)231-54 Semel ME Resch S Haynes AB Funk LM Bader A Berry WR Weiser TG
Gawande AA Adopting a surgical safety checklist could save money and improve the quality of care in US hospitals Health Affairs 2010 29(9)1593-9
5 Haynes B et al Changes in safety attitude and relationships to decreased postoperative morbidity and mortality following implementation of a checklist- based surgical safety intervention BMJ Qual Safety 2011 20102-7
6 httpwwwwhointpatientsafetysafesurgerytools_resourcesenindexhtml
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Correct PPS Policy conthellip
bull Three stage process
1 Days to hours before procedure
2 Just before entering the operating theatre or treatment room
3 Immediately prior to the procedure
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Surgical Safety - Australian Response2004 AHMC endorses the 5-step C3 Protocol
2005 WA Correct PPS Policy 1st Ed
2006 Revised WA Correct PPS Policy
2008 National Compliance Audit C3 Protocolndash Variance amp deficits identified
2009 Local Compliance Audit (WA)ndash Variance amp deficits identified
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Correct PPS WA Audit Resultsbull Six hospital sites audited Oct 08 ndash Feb 09bull Considerable variance in compliance
ndash Obtaining valid consent (esp prior to administration of pre-surgery medication)
ndash Marking the surgical sitendash Final Team Time Out (esp verification of site marking
participation of anaesthetists)ndash Verification of documents amp diagnostic images
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Correct PPS WA Audit Resultsbull Six hospital sites audited Oct 08 ndash Feb 09bull Considerable variance in compliance
ndash Obtaining valid consent (esp prior to administration of pre-surgery medication)
ndash Marking the surgical sitendash Final Team Time Out (esp verification of site marking
participation of anaesthetists)ndash Verification of documents amp diagnostic images
RecommendationUpdate Correct PPS policy facilitate
implementation WHO Checklist
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Australian Response (cont)Nov 2009
ndash AHMC endorses the WHO Surgical Safety Checklist (Checklist) as agreed national strategy for surgical safety
ndash All jurisdictions to have implemented locally adapted versions by July 2011
Nov 2009ndash WA MDF endorses Checklist recommending that it be
implemented as minimum standard across WA Health
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
WHO Checklist Endorsementbull Royal Australasian College of Surgeonsbull Australian and New Zealand College of Anaesthetistsbull Royal Australian and New Zealand College of
Obstetricians and Gynaecologistsbull Royal Australian and New Zealand College of
Ophthalmologistsbull Australian College of Operating Room Nursesbull WA Medical Directorsrsquo Forum
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
WA Health Surgical Safety Checklistbull Developed throughout 2010 bull Extensive stakeholder consultation and strong
agreement consensusbull Contains ALL components of C3 Protocolbull Modest changes and adaptation to WA contextbull Rolled out in November 2010bull Operational Directive OD 031611 March 2011
httpwwwhealthwagovaucircularsnewcircularcfmCirc_ID=12773
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Adapted From
WHO SSC Implementation Manual (2009)
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
WA Health Surgical Safety Checklist (cont)
bull Minimum standardbull Sites health services can ADD elements and
move elements between phasesbull 3-phase structure must be preservedbull Signature verification that all elements have
been verbally confirmed
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
WHO Checklist Adaptation Principles
bull Each section Focusedconcisebull Each section Brief (one min per section)bull Each item Actionablebull Designed for Verbal usebull Collaborative method of adaptionbull Tested in real situations before endorsementbull Integrated into routine processes
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Next StepshellipOSQH
bull Revise WA Correct PPS Policyndash Policy framework for the WA Checklist
bull Continued liaison w ACSQHC re checklists for other specialties
bull Evaluation of WA Checklist 2012ndash Auditndash Surveysndash Other data sources (AIMS HDMS)
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Next Stepshellipyou
bull Understand Checklist amp evidence bull Identify key people
ndash SampQndash Surgical nursing leads
bull Get involvedndash Auditndash Adaptndash Participation
bull Introduce
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Contact
For further information or feedback contact
Tel (08) 9222 4080 Fax (08) 9222 4324 E-mail safetyandqualityhealthwagovauWeb httpwwwsafetyandqualityhealthwagovau
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
References1 Haynes B et al A surgical safety checklist to reduce morbidity and mortality in a
global population New England Journal of Medicine 2009 360 491-92 Gawande A The Checklist Manifesto ndash How to get things right 2009
MacMillan Press3 Hales BM Pronovost PJ The checklist--a tool for error management and
performance improvement Journal of Critical Care 2006 21(3)231-54 Semel ME Resch S Haynes AB Funk LM Bader A Berry WR Weiser TG
Gawande AA Adopting a surgical safety checklist could save money and improve the quality of care in US hospitals Health Affairs 2010 29(9)1593-9
5 Haynes B et al Changes in safety attitude and relationships to decreased postoperative morbidity and mortality following implementation of a checklist- based surgical safety intervention BMJ Qual Safety 2011 20102-7
6 httpwwwwhointpatientsafetysafesurgerytools_resourcesenindexhtml
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Surgical Safety - Australian Response2004 AHMC endorses the 5-step C3 Protocol
2005 WA Correct PPS Policy 1st Ed
2006 Revised WA Correct PPS Policy
2008 National Compliance Audit C3 Protocolndash Variance amp deficits identified
2009 Local Compliance Audit (WA)ndash Variance amp deficits identified
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Correct PPS WA Audit Resultsbull Six hospital sites audited Oct 08 ndash Feb 09bull Considerable variance in compliance
ndash Obtaining valid consent (esp prior to administration of pre-surgery medication)
ndash Marking the surgical sitendash Final Team Time Out (esp verification of site marking
participation of anaesthetists)ndash Verification of documents amp diagnostic images
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Correct PPS WA Audit Resultsbull Six hospital sites audited Oct 08 ndash Feb 09bull Considerable variance in compliance
ndash Obtaining valid consent (esp prior to administration of pre-surgery medication)
ndash Marking the surgical sitendash Final Team Time Out (esp verification of site marking
participation of anaesthetists)ndash Verification of documents amp diagnostic images
RecommendationUpdate Correct PPS policy facilitate
implementation WHO Checklist
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Australian Response (cont)Nov 2009
ndash AHMC endorses the WHO Surgical Safety Checklist (Checklist) as agreed national strategy for surgical safety
ndash All jurisdictions to have implemented locally adapted versions by July 2011
Nov 2009ndash WA MDF endorses Checklist recommending that it be
implemented as minimum standard across WA Health
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
WHO Checklist Endorsementbull Royal Australasian College of Surgeonsbull Australian and New Zealand College of Anaesthetistsbull Royal Australian and New Zealand College of
Obstetricians and Gynaecologistsbull Royal Australian and New Zealand College of
Ophthalmologistsbull Australian College of Operating Room Nursesbull WA Medical Directorsrsquo Forum
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
WA Health Surgical Safety Checklistbull Developed throughout 2010 bull Extensive stakeholder consultation and strong
agreement consensusbull Contains ALL components of C3 Protocolbull Modest changes and adaptation to WA contextbull Rolled out in November 2010bull Operational Directive OD 031611 March 2011
httpwwwhealthwagovaucircularsnewcircularcfmCirc_ID=12773
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Adapted From
WHO SSC Implementation Manual (2009)
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
WA Health Surgical Safety Checklist (cont)
bull Minimum standardbull Sites health services can ADD elements and
move elements between phasesbull 3-phase structure must be preservedbull Signature verification that all elements have
been verbally confirmed
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
WHO Checklist Adaptation Principles
bull Each section Focusedconcisebull Each section Brief (one min per section)bull Each item Actionablebull Designed for Verbal usebull Collaborative method of adaptionbull Tested in real situations before endorsementbull Integrated into routine processes
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Next StepshellipOSQH
bull Revise WA Correct PPS Policyndash Policy framework for the WA Checklist
bull Continued liaison w ACSQHC re checklists for other specialties
bull Evaluation of WA Checklist 2012ndash Auditndash Surveysndash Other data sources (AIMS HDMS)
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Next Stepshellipyou
bull Understand Checklist amp evidence bull Identify key people
ndash SampQndash Surgical nursing leads
bull Get involvedndash Auditndash Adaptndash Participation
bull Introduce
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Contact
For further information or feedback contact
Tel (08) 9222 4080 Fax (08) 9222 4324 E-mail safetyandqualityhealthwagovauWeb httpwwwsafetyandqualityhealthwagovau
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
References1 Haynes B et al A surgical safety checklist to reduce morbidity and mortality in a
global population New England Journal of Medicine 2009 360 491-92 Gawande A The Checklist Manifesto ndash How to get things right 2009
MacMillan Press3 Hales BM Pronovost PJ The checklist--a tool for error management and
performance improvement Journal of Critical Care 2006 21(3)231-54 Semel ME Resch S Haynes AB Funk LM Bader A Berry WR Weiser TG
Gawande AA Adopting a surgical safety checklist could save money and improve the quality of care in US hospitals Health Affairs 2010 29(9)1593-9
5 Haynes B et al Changes in safety attitude and relationships to decreased postoperative morbidity and mortality following implementation of a checklist- based surgical safety intervention BMJ Qual Safety 2011 20102-7
6 httpwwwwhointpatientsafetysafesurgerytools_resourcesenindexhtml
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Correct PPS WA Audit Resultsbull Six hospital sites audited Oct 08 ndash Feb 09bull Considerable variance in compliance
ndash Obtaining valid consent (esp prior to administration of pre-surgery medication)
ndash Marking the surgical sitendash Final Team Time Out (esp verification of site marking
participation of anaesthetists)ndash Verification of documents amp diagnostic images
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Correct PPS WA Audit Resultsbull Six hospital sites audited Oct 08 ndash Feb 09bull Considerable variance in compliance
ndash Obtaining valid consent (esp prior to administration of pre-surgery medication)
ndash Marking the surgical sitendash Final Team Time Out (esp verification of site marking
participation of anaesthetists)ndash Verification of documents amp diagnostic images
RecommendationUpdate Correct PPS policy facilitate
implementation WHO Checklist
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Australian Response (cont)Nov 2009
ndash AHMC endorses the WHO Surgical Safety Checklist (Checklist) as agreed national strategy for surgical safety
ndash All jurisdictions to have implemented locally adapted versions by July 2011
Nov 2009ndash WA MDF endorses Checklist recommending that it be
implemented as minimum standard across WA Health
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
WHO Checklist Endorsementbull Royal Australasian College of Surgeonsbull Australian and New Zealand College of Anaesthetistsbull Royal Australian and New Zealand College of
Obstetricians and Gynaecologistsbull Royal Australian and New Zealand College of
Ophthalmologistsbull Australian College of Operating Room Nursesbull WA Medical Directorsrsquo Forum
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
WA Health Surgical Safety Checklistbull Developed throughout 2010 bull Extensive stakeholder consultation and strong
agreement consensusbull Contains ALL components of C3 Protocolbull Modest changes and adaptation to WA contextbull Rolled out in November 2010bull Operational Directive OD 031611 March 2011
httpwwwhealthwagovaucircularsnewcircularcfmCirc_ID=12773
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Adapted From
WHO SSC Implementation Manual (2009)
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
WA Health Surgical Safety Checklist (cont)
bull Minimum standardbull Sites health services can ADD elements and
move elements between phasesbull 3-phase structure must be preservedbull Signature verification that all elements have
been verbally confirmed
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
WHO Checklist Adaptation Principles
bull Each section Focusedconcisebull Each section Brief (one min per section)bull Each item Actionablebull Designed for Verbal usebull Collaborative method of adaptionbull Tested in real situations before endorsementbull Integrated into routine processes
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Next StepshellipOSQH
bull Revise WA Correct PPS Policyndash Policy framework for the WA Checklist
bull Continued liaison w ACSQHC re checklists for other specialties
bull Evaluation of WA Checklist 2012ndash Auditndash Surveysndash Other data sources (AIMS HDMS)
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Next Stepshellipyou
bull Understand Checklist amp evidence bull Identify key people
ndash SampQndash Surgical nursing leads
bull Get involvedndash Auditndash Adaptndash Participation
bull Introduce
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Contact
For further information or feedback contact
Tel (08) 9222 4080 Fax (08) 9222 4324 E-mail safetyandqualityhealthwagovauWeb httpwwwsafetyandqualityhealthwagovau
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
References1 Haynes B et al A surgical safety checklist to reduce morbidity and mortality in a
global population New England Journal of Medicine 2009 360 491-92 Gawande A The Checklist Manifesto ndash How to get things right 2009
MacMillan Press3 Hales BM Pronovost PJ The checklist--a tool for error management and
performance improvement Journal of Critical Care 2006 21(3)231-54 Semel ME Resch S Haynes AB Funk LM Bader A Berry WR Weiser TG
Gawande AA Adopting a surgical safety checklist could save money and improve the quality of care in US hospitals Health Affairs 2010 29(9)1593-9
5 Haynes B et al Changes in safety attitude and relationships to decreased postoperative morbidity and mortality following implementation of a checklist- based surgical safety intervention BMJ Qual Safety 2011 20102-7
6 httpwwwwhointpatientsafetysafesurgerytools_resourcesenindexhtml
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Correct PPS WA Audit Resultsbull Six hospital sites audited Oct 08 ndash Feb 09bull Considerable variance in compliance
ndash Obtaining valid consent (esp prior to administration of pre-surgery medication)
ndash Marking the surgical sitendash Final Team Time Out (esp verification of site marking
participation of anaesthetists)ndash Verification of documents amp diagnostic images
RecommendationUpdate Correct PPS policy facilitate
implementation WHO Checklist
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Australian Response (cont)Nov 2009
ndash AHMC endorses the WHO Surgical Safety Checklist (Checklist) as agreed national strategy for surgical safety
ndash All jurisdictions to have implemented locally adapted versions by July 2011
Nov 2009ndash WA MDF endorses Checklist recommending that it be
implemented as minimum standard across WA Health
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
WHO Checklist Endorsementbull Royal Australasian College of Surgeonsbull Australian and New Zealand College of Anaesthetistsbull Royal Australian and New Zealand College of
Obstetricians and Gynaecologistsbull Royal Australian and New Zealand College of
Ophthalmologistsbull Australian College of Operating Room Nursesbull WA Medical Directorsrsquo Forum
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
WA Health Surgical Safety Checklistbull Developed throughout 2010 bull Extensive stakeholder consultation and strong
agreement consensusbull Contains ALL components of C3 Protocolbull Modest changes and adaptation to WA contextbull Rolled out in November 2010bull Operational Directive OD 031611 March 2011
httpwwwhealthwagovaucircularsnewcircularcfmCirc_ID=12773
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Adapted From
WHO SSC Implementation Manual (2009)
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
WA Health Surgical Safety Checklist (cont)
bull Minimum standardbull Sites health services can ADD elements and
move elements between phasesbull 3-phase structure must be preservedbull Signature verification that all elements have
been verbally confirmed
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
WHO Checklist Adaptation Principles
bull Each section Focusedconcisebull Each section Brief (one min per section)bull Each item Actionablebull Designed for Verbal usebull Collaborative method of adaptionbull Tested in real situations before endorsementbull Integrated into routine processes
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Next StepshellipOSQH
bull Revise WA Correct PPS Policyndash Policy framework for the WA Checklist
bull Continued liaison w ACSQHC re checklists for other specialties
bull Evaluation of WA Checklist 2012ndash Auditndash Surveysndash Other data sources (AIMS HDMS)
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Next Stepshellipyou
bull Understand Checklist amp evidence bull Identify key people
ndash SampQndash Surgical nursing leads
bull Get involvedndash Auditndash Adaptndash Participation
bull Introduce
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Contact
For further information or feedback contact
Tel (08) 9222 4080 Fax (08) 9222 4324 E-mail safetyandqualityhealthwagovauWeb httpwwwsafetyandqualityhealthwagovau
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
References1 Haynes B et al A surgical safety checklist to reduce morbidity and mortality in a
global population New England Journal of Medicine 2009 360 491-92 Gawande A The Checklist Manifesto ndash How to get things right 2009
MacMillan Press3 Hales BM Pronovost PJ The checklist--a tool for error management and
performance improvement Journal of Critical Care 2006 21(3)231-54 Semel ME Resch S Haynes AB Funk LM Bader A Berry WR Weiser TG
Gawande AA Adopting a surgical safety checklist could save money and improve the quality of care in US hospitals Health Affairs 2010 29(9)1593-9
5 Haynes B et al Changes in safety attitude and relationships to decreased postoperative morbidity and mortality following implementation of a checklist- based surgical safety intervention BMJ Qual Safety 2011 20102-7
6 httpwwwwhointpatientsafetysafesurgerytools_resourcesenindexhtml
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Australian Response (cont)Nov 2009
ndash AHMC endorses the WHO Surgical Safety Checklist (Checklist) as agreed national strategy for surgical safety
ndash All jurisdictions to have implemented locally adapted versions by July 2011
Nov 2009ndash WA MDF endorses Checklist recommending that it be
implemented as minimum standard across WA Health
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
WHO Checklist Endorsementbull Royal Australasian College of Surgeonsbull Australian and New Zealand College of Anaesthetistsbull Royal Australian and New Zealand College of
Obstetricians and Gynaecologistsbull Royal Australian and New Zealand College of
Ophthalmologistsbull Australian College of Operating Room Nursesbull WA Medical Directorsrsquo Forum
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
WA Health Surgical Safety Checklistbull Developed throughout 2010 bull Extensive stakeholder consultation and strong
agreement consensusbull Contains ALL components of C3 Protocolbull Modest changes and adaptation to WA contextbull Rolled out in November 2010bull Operational Directive OD 031611 March 2011
httpwwwhealthwagovaucircularsnewcircularcfmCirc_ID=12773
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Adapted From
WHO SSC Implementation Manual (2009)
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
WA Health Surgical Safety Checklist (cont)
bull Minimum standardbull Sites health services can ADD elements and
move elements between phasesbull 3-phase structure must be preservedbull Signature verification that all elements have
been verbally confirmed
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
WHO Checklist Adaptation Principles
bull Each section Focusedconcisebull Each section Brief (one min per section)bull Each item Actionablebull Designed for Verbal usebull Collaborative method of adaptionbull Tested in real situations before endorsementbull Integrated into routine processes
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Next StepshellipOSQH
bull Revise WA Correct PPS Policyndash Policy framework for the WA Checklist
bull Continued liaison w ACSQHC re checklists for other specialties
bull Evaluation of WA Checklist 2012ndash Auditndash Surveysndash Other data sources (AIMS HDMS)
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Next Stepshellipyou
bull Understand Checklist amp evidence bull Identify key people
ndash SampQndash Surgical nursing leads
bull Get involvedndash Auditndash Adaptndash Participation
bull Introduce
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Contact
For further information or feedback contact
Tel (08) 9222 4080 Fax (08) 9222 4324 E-mail safetyandqualityhealthwagovauWeb httpwwwsafetyandqualityhealthwagovau
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
References1 Haynes B et al A surgical safety checklist to reduce morbidity and mortality in a
global population New England Journal of Medicine 2009 360 491-92 Gawande A The Checklist Manifesto ndash How to get things right 2009
MacMillan Press3 Hales BM Pronovost PJ The checklist--a tool for error management and
performance improvement Journal of Critical Care 2006 21(3)231-54 Semel ME Resch S Haynes AB Funk LM Bader A Berry WR Weiser TG
Gawande AA Adopting a surgical safety checklist could save money and improve the quality of care in US hospitals Health Affairs 2010 29(9)1593-9
5 Haynes B et al Changes in safety attitude and relationships to decreased postoperative morbidity and mortality following implementation of a checklist- based surgical safety intervention BMJ Qual Safety 2011 20102-7
6 httpwwwwhointpatientsafetysafesurgerytools_resourcesenindexhtml
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
WHO Checklist Endorsementbull Royal Australasian College of Surgeonsbull Australian and New Zealand College of Anaesthetistsbull Royal Australian and New Zealand College of
Obstetricians and Gynaecologistsbull Royal Australian and New Zealand College of
Ophthalmologistsbull Australian College of Operating Room Nursesbull WA Medical Directorsrsquo Forum
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
WA Health Surgical Safety Checklistbull Developed throughout 2010 bull Extensive stakeholder consultation and strong
agreement consensusbull Contains ALL components of C3 Protocolbull Modest changes and adaptation to WA contextbull Rolled out in November 2010bull Operational Directive OD 031611 March 2011
httpwwwhealthwagovaucircularsnewcircularcfmCirc_ID=12773
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Adapted From
WHO SSC Implementation Manual (2009)
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
WA Health Surgical Safety Checklist (cont)
bull Minimum standardbull Sites health services can ADD elements and
move elements between phasesbull 3-phase structure must be preservedbull Signature verification that all elements have
been verbally confirmed
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
WHO Checklist Adaptation Principles
bull Each section Focusedconcisebull Each section Brief (one min per section)bull Each item Actionablebull Designed for Verbal usebull Collaborative method of adaptionbull Tested in real situations before endorsementbull Integrated into routine processes
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Next StepshellipOSQH
bull Revise WA Correct PPS Policyndash Policy framework for the WA Checklist
bull Continued liaison w ACSQHC re checklists for other specialties
bull Evaluation of WA Checklist 2012ndash Auditndash Surveysndash Other data sources (AIMS HDMS)
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Next Stepshellipyou
bull Understand Checklist amp evidence bull Identify key people
ndash SampQndash Surgical nursing leads
bull Get involvedndash Auditndash Adaptndash Participation
bull Introduce
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Contact
For further information or feedback contact
Tel (08) 9222 4080 Fax (08) 9222 4324 E-mail safetyandqualityhealthwagovauWeb httpwwwsafetyandqualityhealthwagovau
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
References1 Haynes B et al A surgical safety checklist to reduce morbidity and mortality in a
global population New England Journal of Medicine 2009 360 491-92 Gawande A The Checklist Manifesto ndash How to get things right 2009
MacMillan Press3 Hales BM Pronovost PJ The checklist--a tool for error management and
performance improvement Journal of Critical Care 2006 21(3)231-54 Semel ME Resch S Haynes AB Funk LM Bader A Berry WR Weiser TG
Gawande AA Adopting a surgical safety checklist could save money and improve the quality of care in US hospitals Health Affairs 2010 29(9)1593-9
5 Haynes B et al Changes in safety attitude and relationships to decreased postoperative morbidity and mortality following implementation of a checklist- based surgical safety intervention BMJ Qual Safety 2011 20102-7
6 httpwwwwhointpatientsafetysafesurgerytools_resourcesenindexhtml
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
WA Health Surgical Safety Checklistbull Developed throughout 2010 bull Extensive stakeholder consultation and strong
agreement consensusbull Contains ALL components of C3 Protocolbull Modest changes and adaptation to WA contextbull Rolled out in November 2010bull Operational Directive OD 031611 March 2011
httpwwwhealthwagovaucircularsnewcircularcfmCirc_ID=12773
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Adapted From
WHO SSC Implementation Manual (2009)
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
WA Health Surgical Safety Checklist (cont)
bull Minimum standardbull Sites health services can ADD elements and
move elements between phasesbull 3-phase structure must be preservedbull Signature verification that all elements have
been verbally confirmed
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
WHO Checklist Adaptation Principles
bull Each section Focusedconcisebull Each section Brief (one min per section)bull Each item Actionablebull Designed for Verbal usebull Collaborative method of adaptionbull Tested in real situations before endorsementbull Integrated into routine processes
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Next StepshellipOSQH
bull Revise WA Correct PPS Policyndash Policy framework for the WA Checklist
bull Continued liaison w ACSQHC re checklists for other specialties
bull Evaluation of WA Checklist 2012ndash Auditndash Surveysndash Other data sources (AIMS HDMS)
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Next Stepshellipyou
bull Understand Checklist amp evidence bull Identify key people
ndash SampQndash Surgical nursing leads
bull Get involvedndash Auditndash Adaptndash Participation
bull Introduce
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Contact
For further information or feedback contact
Tel (08) 9222 4080 Fax (08) 9222 4324 E-mail safetyandqualityhealthwagovauWeb httpwwwsafetyandqualityhealthwagovau
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
References1 Haynes B et al A surgical safety checklist to reduce morbidity and mortality in a
global population New England Journal of Medicine 2009 360 491-92 Gawande A The Checklist Manifesto ndash How to get things right 2009
MacMillan Press3 Hales BM Pronovost PJ The checklist--a tool for error management and
performance improvement Journal of Critical Care 2006 21(3)231-54 Semel ME Resch S Haynes AB Funk LM Bader A Berry WR Weiser TG
Gawande AA Adopting a surgical safety checklist could save money and improve the quality of care in US hospitals Health Affairs 2010 29(9)1593-9
5 Haynes B et al Changes in safety attitude and relationships to decreased postoperative morbidity and mortality following implementation of a checklist- based surgical safety intervention BMJ Qual Safety 2011 20102-7
6 httpwwwwhointpatientsafetysafesurgerytools_resourcesenindexhtml
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Adapted From
WHO SSC Implementation Manual (2009)
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
WA Health Surgical Safety Checklist (cont)
bull Minimum standardbull Sites health services can ADD elements and
move elements between phasesbull 3-phase structure must be preservedbull Signature verification that all elements have
been verbally confirmed
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
WHO Checklist Adaptation Principles
bull Each section Focusedconcisebull Each section Brief (one min per section)bull Each item Actionablebull Designed for Verbal usebull Collaborative method of adaptionbull Tested in real situations before endorsementbull Integrated into routine processes
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Next StepshellipOSQH
bull Revise WA Correct PPS Policyndash Policy framework for the WA Checklist
bull Continued liaison w ACSQHC re checklists for other specialties
bull Evaluation of WA Checklist 2012ndash Auditndash Surveysndash Other data sources (AIMS HDMS)
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Next Stepshellipyou
bull Understand Checklist amp evidence bull Identify key people
ndash SampQndash Surgical nursing leads
bull Get involvedndash Auditndash Adaptndash Participation
bull Introduce
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Contact
For further information or feedback contact
Tel (08) 9222 4080 Fax (08) 9222 4324 E-mail safetyandqualityhealthwagovauWeb httpwwwsafetyandqualityhealthwagovau
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
References1 Haynes B et al A surgical safety checklist to reduce morbidity and mortality in a
global population New England Journal of Medicine 2009 360 491-92 Gawande A The Checklist Manifesto ndash How to get things right 2009
MacMillan Press3 Hales BM Pronovost PJ The checklist--a tool for error management and
performance improvement Journal of Critical Care 2006 21(3)231-54 Semel ME Resch S Haynes AB Funk LM Bader A Berry WR Weiser TG
Gawande AA Adopting a surgical safety checklist could save money and improve the quality of care in US hospitals Health Affairs 2010 29(9)1593-9
5 Haynes B et al Changes in safety attitude and relationships to decreased postoperative morbidity and mortality following implementation of a checklist- based surgical safety intervention BMJ Qual Safety 2011 20102-7
6 httpwwwwhointpatientsafetysafesurgerytools_resourcesenindexhtml
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Adapted From
WHO SSC Implementation Manual (2009)
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
WA Health Surgical Safety Checklist (cont)
bull Minimum standardbull Sites health services can ADD elements and
move elements between phasesbull 3-phase structure must be preservedbull Signature verification that all elements have
been verbally confirmed
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
WHO Checklist Adaptation Principles
bull Each section Focusedconcisebull Each section Brief (one min per section)bull Each item Actionablebull Designed for Verbal usebull Collaborative method of adaptionbull Tested in real situations before endorsementbull Integrated into routine processes
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Next StepshellipOSQH
bull Revise WA Correct PPS Policyndash Policy framework for the WA Checklist
bull Continued liaison w ACSQHC re checklists for other specialties
bull Evaluation of WA Checklist 2012ndash Auditndash Surveysndash Other data sources (AIMS HDMS)
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Next Stepshellipyou
bull Understand Checklist amp evidence bull Identify key people
ndash SampQndash Surgical nursing leads
bull Get involvedndash Auditndash Adaptndash Participation
bull Introduce
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Contact
For further information or feedback contact
Tel (08) 9222 4080 Fax (08) 9222 4324 E-mail safetyandqualityhealthwagovauWeb httpwwwsafetyandqualityhealthwagovau
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
References1 Haynes B et al A surgical safety checklist to reduce morbidity and mortality in a
global population New England Journal of Medicine 2009 360 491-92 Gawande A The Checklist Manifesto ndash How to get things right 2009
MacMillan Press3 Hales BM Pronovost PJ The checklist--a tool for error management and
performance improvement Journal of Critical Care 2006 21(3)231-54 Semel ME Resch S Haynes AB Funk LM Bader A Berry WR Weiser TG
Gawande AA Adopting a surgical safety checklist could save money and improve the quality of care in US hospitals Health Affairs 2010 29(9)1593-9
5 Haynes B et al Changes in safety attitude and relationships to decreased postoperative morbidity and mortality following implementation of a checklist- based surgical safety intervention BMJ Qual Safety 2011 20102-7
6 httpwwwwhointpatientsafetysafesurgerytools_resourcesenindexhtml
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Adapted From
WHO SSC Implementation Manual (2009)
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
WA Health Surgical Safety Checklist (cont)
bull Minimum standardbull Sites health services can ADD elements and
move elements between phasesbull 3-phase structure must be preservedbull Signature verification that all elements have
been verbally confirmed
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
WHO Checklist Adaptation Principles
bull Each section Focusedconcisebull Each section Brief (one min per section)bull Each item Actionablebull Designed for Verbal usebull Collaborative method of adaptionbull Tested in real situations before endorsementbull Integrated into routine processes
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Next StepshellipOSQH
bull Revise WA Correct PPS Policyndash Policy framework for the WA Checklist
bull Continued liaison w ACSQHC re checklists for other specialties
bull Evaluation of WA Checklist 2012ndash Auditndash Surveysndash Other data sources (AIMS HDMS)
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Next Stepshellipyou
bull Understand Checklist amp evidence bull Identify key people
ndash SampQndash Surgical nursing leads
bull Get involvedndash Auditndash Adaptndash Participation
bull Introduce
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Contact
For further information or feedback contact
Tel (08) 9222 4080 Fax (08) 9222 4324 E-mail safetyandqualityhealthwagovauWeb httpwwwsafetyandqualityhealthwagovau
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
References1 Haynes B et al A surgical safety checklist to reduce morbidity and mortality in a
global population New England Journal of Medicine 2009 360 491-92 Gawande A The Checklist Manifesto ndash How to get things right 2009
MacMillan Press3 Hales BM Pronovost PJ The checklist--a tool for error management and
performance improvement Journal of Critical Care 2006 21(3)231-54 Semel ME Resch S Haynes AB Funk LM Bader A Berry WR Weiser TG
Gawande AA Adopting a surgical safety checklist could save money and improve the quality of care in US hospitals Health Affairs 2010 29(9)1593-9
5 Haynes B et al Changes in safety attitude and relationships to decreased postoperative morbidity and mortality following implementation of a checklist- based surgical safety intervention BMJ Qual Safety 2011 20102-7
6 httpwwwwhointpatientsafetysafesurgerytools_resourcesenindexhtml
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
WA Health Surgical Safety Checklist (cont)
bull Minimum standardbull Sites health services can ADD elements and
move elements between phasesbull 3-phase structure must be preservedbull Signature verification that all elements have
been verbally confirmed
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
WHO Checklist Adaptation Principles
bull Each section Focusedconcisebull Each section Brief (one min per section)bull Each item Actionablebull Designed for Verbal usebull Collaborative method of adaptionbull Tested in real situations before endorsementbull Integrated into routine processes
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Next StepshellipOSQH
bull Revise WA Correct PPS Policyndash Policy framework for the WA Checklist
bull Continued liaison w ACSQHC re checklists for other specialties
bull Evaluation of WA Checklist 2012ndash Auditndash Surveysndash Other data sources (AIMS HDMS)
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Next Stepshellipyou
bull Understand Checklist amp evidence bull Identify key people
ndash SampQndash Surgical nursing leads
bull Get involvedndash Auditndash Adaptndash Participation
bull Introduce
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Contact
For further information or feedback contact
Tel (08) 9222 4080 Fax (08) 9222 4324 E-mail safetyandqualityhealthwagovauWeb httpwwwsafetyandqualityhealthwagovau
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
References1 Haynes B et al A surgical safety checklist to reduce morbidity and mortality in a
global population New England Journal of Medicine 2009 360 491-92 Gawande A The Checklist Manifesto ndash How to get things right 2009
MacMillan Press3 Hales BM Pronovost PJ The checklist--a tool for error management and
performance improvement Journal of Critical Care 2006 21(3)231-54 Semel ME Resch S Haynes AB Funk LM Bader A Berry WR Weiser TG
Gawande AA Adopting a surgical safety checklist could save money and improve the quality of care in US hospitals Health Affairs 2010 29(9)1593-9
5 Haynes B et al Changes in safety attitude and relationships to decreased postoperative morbidity and mortality following implementation of a checklist- based surgical safety intervention BMJ Qual Safety 2011 20102-7
6 httpwwwwhointpatientsafetysafesurgerytools_resourcesenindexhtml
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
WHO Checklist Adaptation Principles
bull Each section Focusedconcisebull Each section Brief (one min per section)bull Each item Actionablebull Designed for Verbal usebull Collaborative method of adaptionbull Tested in real situations before endorsementbull Integrated into routine processes
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Next StepshellipOSQH
bull Revise WA Correct PPS Policyndash Policy framework for the WA Checklist
bull Continued liaison w ACSQHC re checklists for other specialties
bull Evaluation of WA Checklist 2012ndash Auditndash Surveysndash Other data sources (AIMS HDMS)
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Next Stepshellipyou
bull Understand Checklist amp evidence bull Identify key people
ndash SampQndash Surgical nursing leads
bull Get involvedndash Auditndash Adaptndash Participation
bull Introduce
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Contact
For further information or feedback contact
Tel (08) 9222 4080 Fax (08) 9222 4324 E-mail safetyandqualityhealthwagovauWeb httpwwwsafetyandqualityhealthwagovau
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
References1 Haynes B et al A surgical safety checklist to reduce morbidity and mortality in a
global population New England Journal of Medicine 2009 360 491-92 Gawande A The Checklist Manifesto ndash How to get things right 2009
MacMillan Press3 Hales BM Pronovost PJ The checklist--a tool for error management and
performance improvement Journal of Critical Care 2006 21(3)231-54 Semel ME Resch S Haynes AB Funk LM Bader A Berry WR Weiser TG
Gawande AA Adopting a surgical safety checklist could save money and improve the quality of care in US hospitals Health Affairs 2010 29(9)1593-9
5 Haynes B et al Changes in safety attitude and relationships to decreased postoperative morbidity and mortality following implementation of a checklist- based surgical safety intervention BMJ Qual Safety 2011 20102-7
6 httpwwwwhointpatientsafetysafesurgerytools_resourcesenindexhtml
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Next StepshellipOSQH
bull Revise WA Correct PPS Policyndash Policy framework for the WA Checklist
bull Continued liaison w ACSQHC re checklists for other specialties
bull Evaluation of WA Checklist 2012ndash Auditndash Surveysndash Other data sources (AIMS HDMS)
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Next Stepshellipyou
bull Understand Checklist amp evidence bull Identify key people
ndash SampQndash Surgical nursing leads
bull Get involvedndash Auditndash Adaptndash Participation
bull Introduce
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Contact
For further information or feedback contact
Tel (08) 9222 4080 Fax (08) 9222 4324 E-mail safetyandqualityhealthwagovauWeb httpwwwsafetyandqualityhealthwagovau
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
References1 Haynes B et al A surgical safety checklist to reduce morbidity and mortality in a
global population New England Journal of Medicine 2009 360 491-92 Gawande A The Checklist Manifesto ndash How to get things right 2009
MacMillan Press3 Hales BM Pronovost PJ The checklist--a tool for error management and
performance improvement Journal of Critical Care 2006 21(3)231-54 Semel ME Resch S Haynes AB Funk LM Bader A Berry WR Weiser TG
Gawande AA Adopting a surgical safety checklist could save money and improve the quality of care in US hospitals Health Affairs 2010 29(9)1593-9
5 Haynes B et al Changes in safety attitude and relationships to decreased postoperative morbidity and mortality following implementation of a checklist- based surgical safety intervention BMJ Qual Safety 2011 20102-7
6 httpwwwwhointpatientsafetysafesurgerytools_resourcesenindexhtml
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Next Stepshellipyou
bull Understand Checklist amp evidence bull Identify key people
ndash SampQndash Surgical nursing leads
bull Get involvedndash Auditndash Adaptndash Participation
bull Introduce
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Contact
For further information or feedback contact
Tel (08) 9222 4080 Fax (08) 9222 4324 E-mail safetyandqualityhealthwagovauWeb httpwwwsafetyandqualityhealthwagovau
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
References1 Haynes B et al A surgical safety checklist to reduce morbidity and mortality in a
global population New England Journal of Medicine 2009 360 491-92 Gawande A The Checklist Manifesto ndash How to get things right 2009
MacMillan Press3 Hales BM Pronovost PJ The checklist--a tool for error management and
performance improvement Journal of Critical Care 2006 21(3)231-54 Semel ME Resch S Haynes AB Funk LM Bader A Berry WR Weiser TG
Gawande AA Adopting a surgical safety checklist could save money and improve the quality of care in US hospitals Health Affairs 2010 29(9)1593-9
5 Haynes B et al Changes in safety attitude and relationships to decreased postoperative morbidity and mortality following implementation of a checklist- based surgical safety intervention BMJ Qual Safety 2011 20102-7
6 httpwwwwhointpatientsafetysafesurgerytools_resourcesenindexhtml
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
Contact
For further information or feedback contact
Tel (08) 9222 4080 Fax (08) 9222 4324 E-mail safetyandqualityhealthwagovauWeb httpwwwsafetyandqualityhealthwagovau
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
References1 Haynes B et al A surgical safety checklist to reduce morbidity and mortality in a
global population New England Journal of Medicine 2009 360 491-92 Gawande A The Checklist Manifesto ndash How to get things right 2009
MacMillan Press3 Hales BM Pronovost PJ The checklist--a tool for error management and
performance improvement Journal of Critical Care 2006 21(3)231-54 Semel ME Resch S Haynes AB Funk LM Bader A Berry WR Weiser TG
Gawande AA Adopting a surgical safety checklist could save money and improve the quality of care in US hospitals Health Affairs 2010 29(9)1593-9
5 Haynes B et al Changes in safety attitude and relationships to decreased postoperative morbidity and mortality following implementation of a checklist- based surgical safety intervention BMJ Qual Safety 2011 20102-7
6 httpwwwwhointpatientsafetysafesurgerytools_resourcesenindexhtml
Lead Transform Achieve Together Lead Transform Achieve Together Lead Transform Achieve Together
Office of Safety and Quality
References1 Haynes B et al A surgical safety checklist to reduce morbidity and mortality in a
global population New England Journal of Medicine 2009 360 491-92 Gawande A The Checklist Manifesto ndash How to get things right 2009
MacMillan Press3 Hales BM Pronovost PJ The checklist--a tool for error management and
performance improvement Journal of Critical Care 2006 21(3)231-54 Semel ME Resch S Haynes AB Funk LM Bader A Berry WR Weiser TG
Gawande AA Adopting a surgical safety checklist could save money and improve the quality of care in US hospitals Health Affairs 2010 29(9)1593-9
5 Haynes B et al Changes in safety attitude and relationships to decreased postoperative morbidity and mortality following implementation of a checklist- based surgical safety intervention BMJ Qual Safety 2011 20102-7
6 httpwwwwhointpatientsafetysafesurgerytools_resourcesenindexhtml
