title: A prospective, observational study of the effects of implementation strategy on compliance with a surgical safety checklist.
abstract: BACKGROUND
  The reported benefits of using the WHO Surgical Safety Checklist (SSC) are likely to depend on compliance with its correct use. Compliance with SSC administration in centres that have introduced the checklist under a research protocol may differ from centres where the SSC is introduced independently.
  
  
  OBJECTIVE
  To compare compliance with SSC administration at an original WHO pilot study centre (Hospital 1) with that at a similar neighbouring hospital (Hospital 2) that independently integrated the SSC with pre-existing practice.
  
  
  METHODS
  This was a prospective, observational study. One hundred operations were observed at each hospital. We recorded: compliance with administration of SSC domains (Sign In, Time Out and Sign Out) and individual domain items; timing of domain administration; and operating room team engagement during administration.
  
  
  RESULTS
  Domain compliance at Hospital 1 and Hospital 2, respectively, was: 96% and 31% (p<0.0005) for Sign In; 99% and 48% (p<0.0005) for Time Out and 22% and 9% (p=0.008) for Sign Out. Engagement of two or more teams during Sign In and Time Out occurred more frequently at Hospital 2 than at Hospital 1.
  
  
  CONCLUSIONS
  Compliance with administration of SSC domains was lower at Hospital 2 which introduced the SSC outside the context of a strict study protocol. This finding mandates caution in extrapolation of benefits identified in SSC studies to non-study hospitals. Staff engagement was better at Hospital 2 where checklist administration leadership is strategically shared among anaesthetic, surgical and nursing team members as compared with exclusive nursing leadership at Hospital 1.
  Australian and New Zealand Clinical Trials Registry: Ref: ACTRN12612000135819, http://www.anzctr.org.au/trial_view.aspx?ID=362007.
authors.affiliation: Department of Anaesthesiology, Faculty of Medical and Health Sciences, University of Auckland, , Auckland, New Zealand.
authors.forename: J A
authors.initials: JA
authors.lastname: Hannam
authors.forename: L
authors.initials: L
authors.lastname: Glass
authors.forename: J
authors.initials: J
authors.lastname: Kwon
authors.forename: J
authors.initials: J
authors.lastname: Windsor
authors.forename: F
authors.initials: F
authors.lastname: Stapelberg
authors.forename: K
authors.initials: K
authors.lastname: Callaghan
authors.forename: A F
authors.initials: AF
authors.lastname: Merry
authors.forename: S J
authors.initials: SJ
authors.lastname: Mitchell
mesh_terms: D057189:Checklist; D002983:Clinical Competence; D003953:Diagnosis-Related Groups; D006801:Humans; D009520:New Zealand; D010348:Patient Care Team / Q000592:standards*; D061214:Patient Safety; D011183:Postoperative Complications / Q000517:prevention & control*; D011446:Prospective Studies; D011785:Quality Assurance, Health Care; D017751:Safety Management / Q000379:methods*; D013514:Surgical Procedures, Operative / Q000592:standards*; D014944:World Health Organization