title: Barriers and facilitators related to the implementation of surgical safety checklists: a systematic review of the qualitative evidence.
abstract: OBJECTIVE
  The objective of this review is to obtain a better understanding of the user-related barriers against, and facilitators for, the implementation of surgical safety checklists.
  
  
  METHODS
  We searched MEDLINE for articles describing stakeholders' perspectives regarding, and experiences with, the implementation of surgical safety checklists. The quality of the papers was assessed by means of the Qualitative Assessment and Review Instrument. Thematic synthesis was used to integrate the emergent descriptive themes into overall analytical themes.
  
  
  RESULTS
  The synthesis of 18 qualitative studies indicated that implementation requires change in the workflow of healthcare professionals as well as in their perception of the checklist and the perception of patient safety in general. The factors impeding or advancing the required change concentrated around the checklist, the implementation process and the local context. We found that the required safety checks disrupt operating theatre staffs' routines. Furthermore, conflicting priorities and different perspectives and motives of stakeholders complicate checklist implementation. When approaching the checklist as a simple technical intervention, the expectation of cooperation between surgeons, anaesthetists and nurses is often not addressed, reducing the checklist to a tick-off exercise.
  
  
  CONCLUSIONS
  The complex reality in which the checklist needs to be implemented requires an approach that includes more than eliminating barriers and supporting facilitating factors. Implementation leaders must facilitate team learning to foster the mutual understanding of perspectives and motivations, and the realignment of routines. This paper provides a pragmatic overview of the user-related barriers and facilitators upon which theories, hypothesising potential change strategies and interactions, can be developed and tested empirically.
authors.affiliation: Faculty of Business Economics, Hasselt University, Hasselt, Belgium.
authors.forename: Jochen
authors.initials: J
authors.lastname: Bergs
authors.affiliation: Faculty of Business Economics, Hasselt University, Hasselt, Belgium.
authors.forename: Frank
authors.initials: F
authors.lastname: Lambrechts
authors.affiliation: Faculty of Business Economics, Hasselt University, Hasselt, Belgium.
authors.forename: Pascale
authors.initials: P
authors.lastname: Simons
authors.affiliation: Faculty of Medicine and Life Sciences, Hasselt University, Hasselt, Belgium.
authors.forename: Annemie
authors.initials: A
authors.lastname: Vlayen
authors.affiliation: Faculty of Business Economics, Hasselt University, Hasselt, Belgium.
authors.forename: Wim
authors.initials: W
authors.lastname: Marneffe
authors.affiliation: Faculty of Medicine and Life Sciences, Hasselt University, Hasselt, Belgium Department of Management, General Hospital AZ Delta, Roeselare, Belgium.
authors.forename: Johan
authors.initials: J
authors.lastname: Hellings
authors.affiliation: Belgian Health Care Knowledge Center (KCE), Brussels, Belgium.
authors.forename: Irina
authors.initials: I
authors.lastname: Cleemput
authors.affiliation: Faculty of Medicine and Life Sciences, Hasselt University, Hasselt, Belgium Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium Department of General Internal Medicine, Ghent University Hospital, Ghent, Belgium.
authors.forename: Dominique
authors.initials: D
authors.lastname: Vandijck
mesh_terms: D057189:Checklist / Q000592:standards*; D003142:Communication; D006801:Humans; D007318:Inservice Training; D007857:Leadership; D009873:Operating Rooms / Q000458:organization & administration* / Q000592:standards; D061214:Patient Safety / Q000592:standards*; D010465:Perception; D036301:Qualitative Research; D057188:Workflow
keywords: Checklists; Implementation science; Patient safety; Surgery