title: Implementation of safety checklists in surgery: a realist synthesis of evidence.
abstract: OBJECTIVE
  The aim of this review is to present a realist synthesis of the evidence of implementation interventions to improve adherence to the use of safety checklists in surgery.
  
  
  BACKGROUND
  Surgical safety checklists have been shown to improve teamwork and patient safety in the operating room. Yet, despite the benefits associated with their use, universal implementation of and compliance with these checklists has been inconsistent.
  
  
  METHODS
  An overview of the literature from 2008 is examined in relation to checklist implementation, compliance, and sustainability.
  
  
  METHODS
  Pawson's and Rycroft-Malone's realist synthesis methodology was used to explain the interaction between context, mechanism, and outcome. This approach incorporated the following: defining the scope of the review, searching and appraising the evidence, extracting and synthesising the findings, and disseminating, implementing, and evaluating the evidence. We identified two theories a priori that explained contextual nuances associated with implementation and evaluation of checklists in surgery: the Normalisation Process Theory and Responsive Regulation Theory.
  
  
  RESULTS
  We identified four a priori propositions: (1) Checklist protocols that are prospectively tailored to the context are more likely to be used and sustained in practice, (2) Fidelity and sustainability is increased when checklist protocols can be seamlessly integrated into daily professional practice, (3) Routine embedding of checklist protocols in practice is influenced by factors that promote or inhibit clinicians' participation, and (4) Regulation reinforcement mechanisms that are more contextually responsive should lead to greater compliance in using checklist protocols. The final explanatory model suggests that the sustained use of surgical checklists is discipline-specific and is more likely to occur when medical staff are actively engaged and leading the process of implementation. Involving clinicians in tailoring the checklist to better fit their context of practice and giving them the opportunity to reflect and evaluate the implementation intervention enables greater participation and ownership of the process.
  
  
  CONCLUSIONS
  A major limitation in the surgical checklist literature is the lack of robust descriptions of intervention methods and implementation strategies. Despite this, two consequential findings have emerged through this realist synthesis: First, the sustained use of surgical checklists is discipline-specific and is more successful when physicians are actively engaged and leading implementation. Second, involving clinicians in tailoring the checklist to their context and encouraging them to reflect on and evaluate the implementation process enables greater participation and ownership.
authors.affiliation: NHMRC Centre for Research Excellence in Nursing (NCREN), Centre for Health Practice Innovation (HPI), Menzies Health Institute Qld (MHIQ), Griffith University, Gold Coast Campus, Gold Coast, QLD, 4222, Australia. b.gillespie@griffith.edu.au.
authors.forename: Brigid M
authors.initials: BM
authors.lastname: Gillespie
authors.affiliation: NHMRC Centre for Research Excellence in Nursing (NCREN), Centre for Health Practice Innovation (HPI), Menzies Health Institute Qld (MHIQ), Griffith University, Gold Coast Campus, Gold Coast, QLD, 4222, Australia. a.marshall@griffith.edu.au.|School of Nursing and Midwifery, Griffith University, Gold Coast Campus, Gold Coast, QLD, 4222, Australia. a.marshall@griffith.edu.au.|Gold Coast University Hospital, Gold Coast Hospital and Health Service, Southport, QLD, 4215, Australia. a.marshall@griffith.edu.au.
authors.forename: Andrea
authors.initials: A
authors.lastname: Marshall
mesh_terms: D057189:Checklist / Q000706:statistics & numerical data*; D002985:Clinical Protocols; D004059:Diffusion of Innovation; D019317:Evidence-Based Medicine; D006801:Humans; D007318:Inservice Training / Q000458:organization & administration; D007857:Leadership; D061214:Patient Safety; D015397:Program Evaluation; D012054:Reinforcement, Psychology; D013514:Surgical Procedures, Operative / Q000379:methods*