title: Implementing a surgical checklist: more than checking a box.
abstract: BACKGROUND
  Perioperative checklists are mandated by many hospitals as determined by the reduction in morbidity and mortality seen with the use of the World Health Organization's Surgical Safety Checklist. An adapted perioperative checklist was implemented within our hospital system, and compliance with the checklist was reported to be 100%. We hypothesized that compliance does not measure the fidelity of implementation.
  
  
  METHODS
  During a 7-week period, a prospective study was performed to evaluate the completion of all preincision components of the surgical checklist. Pediatric surgical operations were selected for direct observation. In addition, a poststudy survey was used to assess perception and understanding of the checklist process.
  
  
  RESULTS
  A total of 142 pediatric surgical cases were observed. Hospital reported data demonstrated 100% compliance with the preincision phase of the checklist for these cases. None of the cases completely executed all items on the checklist, and the average number of checklist items performed in the observed cases was 4 of 13. The most commonly performed checkpoint were the confirmation of patient name and procedure (99%) and the "timeout" at the start of the checklist (97%). The rest of the checkpoints were performed in less than 60% of cases. Adherence did not increase during the observation period.
  
  
  CONCLUSIONS
  These data show that despite the 100% documented completion of the preincision phase of the checklist; most of the individual checkpoints are either not executed as designed or not executed at all. These findings demonstrate lack of checklist implementation fidelity, which may be a reflection a poor implementation and dissemination strategy.
authors: Center for Surgical Trials and Evidence-based Practice, Department of Pediatric Surgery, University of Texas Medical School at Houston, 77030, USA.
authors: Shauna M
authors: SM
authors: Levy
authors: Casey E
authors: CE
authors: Senter
authors: Russell B
authors: RB
authors: Hawkins
authors: Jane Y
authors: JY
authors: Zhao
authors: Kaitlin
authors: K
authors: Doody
authors: Lillian S
authors: LS
authors: Kao
authors: Kevin P
authors: KP
authors: Lally
authors: Kuojen
authors: K
authors: Tsao
mesh_terms: D000776:Anesthesiology / Q000458:organization & administration*; D057189:Checklist / Q000379:methods* / Q000706:statistics & numerical data*; D002648:Child; D019983:Guideline Adherence / Q000458:organization & administration / Q000706:statistics & numerical data; D006776:Hospitals, Pediatric / Q000458:organization & administration*; D006801:Humans; D010348:Patient Care Team / Q000458:organization & administration*; D010372:Pediatrics / Q000458:organization & administration; D016730:Program Development; D011446:Prospective Studies; D013503:Surgery Department, Hospital / Q000458:organization & administration*; D013781:Texas