Surgical Safety Checklist Policy · Web viewAt the time of surgery, if any staff member has a concern that the surgical safety checklist is not being followed as per policy, they

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Canberra Health Services Operational PolicySurgical Safety ChecklistPolicy Statement

The Surgical Safety Checklist (SSC) was developed by the World Health Organisation (WHO) to improve surgical safety and reduce mortality rates and the incidence of surgical complications.

The requirement to perform the SSC, as a best practice patient safety initiative (endorsed by Australian Health Ministers, the Royal Australasian College of Surgeons, and the College of Anaesthetists) was implemented at Canberra Health Services (CHS) on 1 February 2011.

The ultimate goal of the SSC is to ensure that staff consistently follow a few critical safety steps and thereby minimise the most common and avoidable risks endangering the lives and well-being of surgical patients.

The WHO SSC identifies three phases of an operation, each corresponding to a specific period in the normal flow of a procedure: Step 1 “sign in”- before the induction of anaesthesia Step 2 “time out”- before the incision of the skin, and Step 3 “sign out”- before the patient leaves the operating room.

The three steps associated with the WHO SSC have been formalised into three distinct phases in CHS, each corresponding to a specific period in the normal flow of a procedure (see Attachment 1).

Step 1 “Check-in”-incorporating the “sign in” step of the WHO SSC (completed before the induction of anaesthesia).Step 2 “Team Time Out”-incorporating the “time out” step of the WHO SSC (performed in the operating room and before incision of the patient’s skin).Step 3 “Check Out”-incorporating the “sign out” step of the WHO SSC. All steps are to occur prior to the patient leaving the operating room.

Pre-operative processThe process starts with the commencement of the Pre-operative Checklist (clinical form 45220) on admission to one of the areas listed below: Inpatient ward Day Surgery Unit Extended Day Surgery Unit.

The patient’s identity, planned procedure and consent must be confirmed as per Consent to Treatment Policy and Patient Identification and Procedure Matching Procedure prior to

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Do not refer to a paper based copy of this policy document. The most current version can be found on the ACT Health Policy Register

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transfer from the admission area to the operating suite or procedure room. If the admission area staff member has any concern about the responses, the patient remains in the admission area until the concern is addressed (“if a box is ticked ‘no’ the patient doesn’t go”).

The paper copy of the Pre-operative Checklist must be discussed and completed by the operating room nursing staff, with the admission area staff member, in holding bay. This clinical handover of the patient, prior to transfer into the anaesthetic bay should include the patient in the discussion where possible.

Marking of the surgical site (when appropriate) must take place in the holding bay. It is performed by a member of the surgical team who will be involved in the procedure: an arrow is placed at or near the surgical site with an indelible pen and initialled by the

surgical team member it should be placed so that it remains visible after draping.

Step 1 Check-inThe check-in process must be undertaken by the anaesthetic nurse and/or anaesthetist in the anaesthetic bay, or procedure room, prior to anaesthesia where they: confirm the patient’s identity, procedure, site and consent with the patient confirm the anaesthesia safety check and attaching pulse oximetry confirm difficult airway/aspiration risk check for drug allergies assess risk of major bleeding (risk of >500mL in adults or 7mL/kg in paediatrics) ensure essential imaging is available ensure site is correctly marked.

Check In must be documented on the pre-op checklist and included in the patient’s clinical notes.

Step 2 Team Time Out (documented electronically in the operating room)This must occur prior to skin incision or commencement of operative procedure. Team Time Out must be performed by the lead Medical Officer responsible for the operating team (Surgeon 1). The operating team which comprises of medical officers, anaesthesia professionals, nurses, technicians and other operating room personnel all of whom play a role in ensuring the safety and success of an operation. During the SSC briefings, all team members must pause, listen and participate by providing a verbal response to other team members. However, it is the surgeon or medical officer performing the surgery that is the designated SSC co-ordinator and is responsible for confirming that the team has completed each task before safe surgery commences.

In the following emergency situations, full completion of the SSC is at the discretion of the lead Medical Officer responsible for the operating team (Surgeon 1): Category 1 – Life threatening <1 hour Category A – Caesarean, delivery within 30 mins



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In these categories only, the lead Medical Officer (Surgeon 1) is responsible for the care of the patient and should decide the most appropriate course of action based on clinical urgency. The decision to modify or delay the completion of the SSC must be documented in the clinical record.

Step 3: Check Out (documented electronically in the operating room)This step must occur following the procedure, before the patient leaves the operating room. Check Out must be performed by the lead Medical Officer responsible for the operating team (Surgeon 1) or their delegate. The operating team comprises of surgeons, anaesthesia professionals, nurses, technicians and other operating room personnel all of whom play a role in ensuring the safety and success of an operation.

The SSC must be completed electronically within the Clinical Portal (see Attachment 1) and on completion is sent electronically to the Clinical Records Information System (CRIS).

Some responses in both steps of the electronic SCC may prompt additional information in a free text response. For example if “yes” is ticked in the anaesthetic concerns box, a box drops down for the anaesthetist to document their specific concerns in relation to anesthetising the patient e.g. identifying potential difficulty in intubating the patient.

AlertThe SSC checklist is not considered complete unless all fields in the Clinical Portal have been completed. The SSC must be completed at the time of the procedure. The SCC should not be retrospectively completed, completed all at the same time, nor completed in advance or conclusion of the procedure.

Escalation for non-compliance with this PolicyNon-compliance with this Policy may be identified immediately or later via compliance reports.

At the time of surgery, if any staff member has a concern that the surgical safety checklist is not being followed as per policy, they must in the first instance voice their concerns to the other members of the operating team and surgery must not proceed.

In the event that surgery proceeds, non-adherence to policy must be immediately reported as an incident to the Clinical Nurse Consultant/Nursing Team Leader who will escalate to the Peri-operative Assistant Director of Nursing (ADON), who is responsible for investigating the incident.

Medical staff must report the incident to the Clinical Director of Surgery directly or the Peri-operative ADON.

A Riskman is to be completed by the person witnessing the incident.

Compliance reports are provided to the Division of Surgery based on data from the Clinical Portal and ACTPAS. If a clinician is identified as having repeatedly breached policy



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requirements, the following process for non-compliance is to be followed (see attachment 2 for further detail): Surgical staff identified as not being 100% compliance will be sent an email with relevant

data detailing their non-compliance during the most recent audit period. Should they be 100% compliant in the following reporting period they will return to the green stage.

Surgical staff identified as not being 100% compliant for more than two consecutive reporting periods, noting surgical activity completed, will be sent a letter detailing their non-compliance including the relevant data for the most recent audit period. An offer to discuss the data will be made along with the expectation that 100% compliance will be achieved by the next audit.

if a medical officer continues not to comply with policy, further action will be taken in accordance with the ACT Public Sector Medical Practitioners Enterprise Agreement 2013-2017 or Visiting Medical Officers Service Contract 2016.

Refer to Attachment 2 for the Performance Management Plan for non-compliance with this Policy.

Monitoring compliance with the SSC Compliance reports are prepared by Quality, Safety, Innovation and Improvement and drawn from data from the Clinical Portal SSC electronic form, completed in the operating room and relevant fields from ACTPAS. Assessment for compliance is against several defined breach categories designed to ensure compliance with the correct process.

The compliance goal is 100% completion of the electronic surgical safety checklist, with a target of 95% in compliance reports to account for potential data entry discrepancies.

Observational audits (five per week) of the Surgical Safety Checklist team briefing are performed by the Division of Surgery.

Note: for procedures outsourced to private sector (e.g. as part of a waiting list initiative), the private provider must provide a performance report to CHS which indicates their compliance with the three steps of the Surgical Safety Checklist which will be reviewed at the time the service contract, Service Level Agreement or Memorandum of Understanding is renewed.

Compliance and observational audit reports are provided to Communicating for Safety National Standard Committee and the Executive Director, Surgery and Oral Health for review and initiation of improvement activity if required.

Purpose



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The purpose of this Policy is to address patient safety and clinical risks associated with surgical procedures by mandating all CHS staff adhere to the correct process for completing the CHS SSC.

The completion of the SSC will improve: surgical safety and reduce both the mortality rates and the incidence of surgical

complications. This will prevent procedures being performed on the wrong patient or body part resulting in death or major permanent loss of function

matching of the patient to the correct procedure, and communication within the surgical team and between the patient and the surgical team.

Scope

This policy applies to all invasive and non-invasive procedures performed in CHS operating rooms.

This document applies to the following CHS staff working within their scope of practice: surgical and anaesthetic medical staff nursing and midwifery staff students under direct supervision, and all other staff employed in the operating room environment e.g. wardsperson,

radiographers.

In the following emergency situations, full completion of the SSC is at the discretion of the lead Medical Officer responsible for the operating team (Surgeon 1): Category 1 – Life threatening <1 hour Category A – Caesarean, delivery within 30 minsIn these categories only, the lead Medical Officer (Surgeon 1) is responsible for the care of the patient and should decide the most appropriate course of action based on clinical urgency. The decision to modify or delay the completion of the SSC must be documented in the clinical record.

Exclusions – Procedures performed in Operating Theatre 1B, Interventional Radiology or Radiation Therapy are excluded from the scope of this policy.

Note: for procedures outsourced to private sector (e.g. as part of a waiting list initiative), the private provider must provide a performance report to CHS which indicates their compliance with the three steps in the Surgical Safety Checklist which will be reviewed at the time the service contract, Service Level Agreement or Memorandum of Understanding is renewed.

Roles & Responsibilities

Surgeon 1 has ultimate responsibility for completing the SSC. Consultants are accountable for ensuring Registrars are aware of their responsibility to complete the SSC.



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The medical officer is responsible for: initiating and leading SSC briefings while the patient is in the operating room reading aloud discussion points on the SSC form providing a verbal response to discussion points raised relevant to the role, and completion of the SSC form by checking a tick box relevant to each discussion point.

The operating team comprises of: surgeon and surgical assistants anaesthetists/anaesthetic registrar scrub and scout nurses, and anaesthetic nurses.

The operating team is responsible for participating in, and performing the SSC.

The Perioperative ADON, the Director of Nursing (DON) SOH, the Clinical Director of Surgery, the Director of Anaesthesia and the Executive Director of the relevant clinical Division are the governing bodies responsible for ensuring the Surgical Safety Checklist is completed appropriately.

The Electronic Surgical Safety Checklist (ESSC) working group provides oversight and advice on compliance documentation for completion of the Surgical Safety Checklist. The ESSC Working Group Chair works in collaboration with the Executive Director and Clinical Director, Division of Surgery and the Clinical Director, Obstetrics and Gynaecology, Women, Youth and Children to ensure that the ESSC is completed as per best practice guidelines. The ESSC Working Group reports monthly to the Communicating for Safety Committee.

Implementation

This Policy will be provided to all new staff upon orientation to the unit. It will be accessible on the Policy Register and communicated via an all staff email alert.

Related Policies, Procedures, Guidelines and Legislation

Policies ACT Health Directorate Nursing and Midwifery Continuing Competence Policy Consent and Treatment Policy Patient Identification and Procedure Matching Policy ACT Health Incident Management Policy

Procedures Patient Identification and Procedure Matching Procedure ACT Health Incident Management Procedure ACT Health Significant Incident Procedure



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Legislation Health Records (Privacy and Access) Act 1997 Human Rights Act 2004

References

1. World Health Organisation: http://www.who.int/patientsafety/safesurgery/ss_checklist/en/

2. NSW Government Health: Clinical Procedure Safety: http://www0.health.nsw.gov.au/policies/pd/2014/pdf/PD2014_036.pdf

Search Terms

Surgical Safety Checklist, Electronic, Peri operative, Operating theatre

Attachments

Attachment 1 – CHS Surgical Safety ChecklistAttachment 2 – Maintenance and Management of the Electronic Surgical Safety Checklist

Disclaimer: This document has been developed by Canberra Health Services specifically for its own use. Use of this document and any reliance on the information contained therein by any third party is at his or her own risk and Canberra Health Services assumes no responsibility whatsoever.

Date Amended Section Amended Approved By14 June 2018 Additions regarding exclusions and

to strengthen alignment with WHOExecutive Sponsor, Standard 5 and Chair, CHHS PC

29 June 2018 Addition of Attachment 2 – Performance Management Plan

Executive Sponsor, Standard 5 and DDG, CHHS

24 January 2019 Amendment to Attachment 2, addition throughout regarding private providers.

DDG CHS and CHS PC Chair

17 June 2019 Amendment to compliance monitoring on page 4 and roles and responsibilities on page 6.

Chair ESSC Working Group and CHS PC Chair



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Attachment 1 – CHS Surgical Safety Checklist

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All surgical staff are aware of the SSC policy and Canberra Health Services expectation of compliance under their employment contracts.New surgical staff are advised by way of a letter in their orientation packs and by conversation held with their supervising surgeons.

Green StageAll surgical staff continue to

be monitored on their compliance of the SSC.

For those that are regularly 100% compliant no further

action will be required.

Amber StageSurgical staff identified as not being 100% compliant will be sent an email with

relevant data detailing their non-compliance during the most recent audit period.

Should they be 100% compliant in the following reporting period they will return to the green stage.

Red StageSurgical staff identified as not being 100% compliant

for more than two consecutive reporting

periods, noting surgical activity completed, will be sent a letter detailing their non-compliance including the relevant data for the

most recent audit period. An offer to discuss the data will be made along with the

expectation that 100% compliance will be achieved

by the next audit.

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Attachment 2 – Maintenance and Management of the Electronic Surgical Safety Checklist


Surgical Safety Checklist Policy · Web viewAt the time of surgery, if any staff member has a concern that the surgical safety checklist is not being followed as per policy, they

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