title: Multifaceted interventions improve adherence to the surgical checklist.
abstract: BACKGROUND
  Adherence to surgical safety checklists remains challenging. Our institution demonstrated acceptable rates of checklist utilization but poor adherence to all checkpoints. We hypothesized that stepwise, multifaceted interventions would improve checklist adherence.
  
  
  METHODS
  From 2011 to 2013, adherence to the 14-point, pre-incision checklist was assessed directly by trained observers during three, 1-year periods (baseline, observation #1, and observation #2) during which interventions were implemented. Interventions included safety workshops, customization of a stakeholder-derived checklist, and implementation of a report card system. Chi-square and Kruskal-Wallis tests were utilized.
  
  
  RESULTS
  Checklist performance was assessed for 873 cases (baseline, n = 144; observation #1, n = 373; observation #2, n = 356). Total checkpoint adherence increased (from 30% to 78% to 96%; P < .001), as did cases with correct completion of all checkpoints (from 0% to 19% to 61%; P < .001). The median (interquartile range) number of checkpoints completed per case improved from 4 (3-5) to 11 (10-12) to 14 (13-14; P < .001).
  
  
  CONCLUSIONS
  A strategic, multifaceted approach to perioperative safety significantly improved checklist adherence over 2 years. Checklist content and process need to reflect local interests and operative flow to achieve high adherence rates. Successful checklist implementation requires efforts to change the safety culture, stakeholder buy-in, and sustained efforts over time.
authors.affiliation: Center for Surgical Trials and Evidence-based Practice, University of Texas Medical School at Houston, Houston, TX; Department of Pediatric Surgery, University of Texas Medical School at Houston, Houston, TX; The Children's Memorial Hermann Hospital, Houston, TX.
authors.forename: Luke R
authors.initials: LR
authors.lastname: Putnam
authors.affiliation: Center for Surgical Trials and Evidence-based Practice, University of Texas Medical School at Houston, Houston, TX; Department of Pediatric Surgery, University of Texas Medical School at Houston, Houston, TX; The Children's Memorial Hermann Hospital, Houston, TX.
authors.forename: Shauna M
authors.initials: SM
authors.lastname: Levy
authors.affiliation: Center for Surgical Trials and Evidence-based Practice, University of Texas Medical School at Houston, Houston, TX; Department of Pediatric Surgery, University of Texas Medical School at Houston, Houston, TX.
authors.forename: Madiha
authors.initials: M
authors.lastname: Sajid
authors.affiliation: Center for Surgical Trials and Evidence-based Practice, University of Texas Medical School at Houston, Houston, TX; Department of Pediatric Surgery, University of Texas Medical School at Houston, Houston, TX.
authors.forename: Danielle A
authors.initials: DA
authors.lastname: Dubuisson
authors.affiliation: Center for Surgical Trials and Evidence-based Practice, University of Texas Medical School at Houston, Houston, TX; Department of Pediatric Surgery, University of Texas Medical School at Houston, Houston, TX.
authors.forename: Nathan B
authors.initials: NB
authors.lastname: Rogers
authors.affiliation: Center for Surgical Trials and Evidence-based Practice, University of Texas Medical School at Houston, Houston, TX; Department of Surgery, University of Texas Medical School at Houston, Houston, TX; The Children's Memorial Hermann Hospital, Houston, TX.
authors.forename: Lillian S
authors.initials: LS
authors.lastname: Kao
authors.affiliation: Center for Surgical Trials and Evidence-based Practice, University of Texas Medical School at Houston, Houston, TX; Department of Pediatric Surgery, University of Texas Medical School at Houston, Houston, TX; The Children's Memorial Hermann Hospital, Houston, TX.
authors.forename: Kevin P
authors.initials: KP
authors.lastname: Lally
authors.affiliation: Center for Surgical Trials and Evidence-based Practice, University of Texas Medical School at Houston, Houston, TX; Department of Pediatric Surgery, University of Texas Medical School at Houston, Houston, TX; The Children's Memorial Hermann Hospital, Houston, TX. Electronic address: kuojen.tsao@uth.tmc.edu.
authors.forename: KuoJen
authors.initials: K
authors.lastname: Tsao
mesh_terms: D057189:Checklist / Q000592:standards*; D002648:Child; D004493:Education; D019983:Guideline Adherence / Q000592:standards; D006776:Hospitals, Pediatric; D006801:Humans; D019300:Medical Errors / Q000517:prevention & control; D009873:Operating Rooms / Q000592:standards; D061214:Patient Safety / Q000592:standards*; D017410:Practice Guidelines as Topic; D013514:Surgical Procedures, Operative / Q000592:standards*; D013781:Texas; D014944:World Health Organization