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Canberra Hospital and Health Services Operational PolicySurgical Safety ChecklistPolicy Statement

The Surgical Safety Checklist (SSC) was developed by the World Health Organisation (WHO) to improve surgical safety and reduce mortality rates and the incidence of surgical complications.

The requirement to perform the SSC, as a best practice patient safety initiative (endorsed by Australian Health Ministers, the Royal Australasian College of Surgeons, and the College of Anaesthetists) was implemented at Canberra Hospital and Health Services (CHHS) on 1 February 2011.

The ultimate goal of the SSC is to ensure that staff consistently follow a few critical safety steps and thereby minimise the most common and avoidable risks endangering the lives and well-being of surgical patients.

The WHO SSC identifies three phases of an operation, each corresponding to a specific period in the normal flow of a procedure: Step 1 “sign in”- before the induction of anaesthesia Step 2 “time out”- before the incision of the skin, and Step 3 “sign out”- before the patient leaves the operating room.

The three steps associated with the WHO SSC have been formalised into three distinct phases in CHHS, each corresponding to a specific period in the normal flow of a procedure (see Attachment 1).

Step 1 “Check-in”-incorporating the “sign in” step of the WHO SSC (completed before the induction of anaesthesia).Step 2 “Team Time Out”-incorporating the “time out” step of the WHO SSC (performed in the operating room and before incision of the patient’s skin).Step 3 “Check Out”-incorporating the “sign out” step of the WHO SSC. All steps are to occur prior to the patient leaving the operating room.

Pre-operative processThe process starts with the commencement of the Pre-operative Checklist (clinical form 45220) on admission to one of the areas listed below: Inpatient ward Day Surgery Unit Extended Day Surgery Unit.

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The patient confirms their identity and planned procedure and consent with staff prior to transfer from the admission area to the operating suite or procedure room. If the admission area staff member has any concern about the responses, the patient remains in the admission area until the concern is addressed (“if a box is ticked ‘no’ the patient doesn’t go”).

The paper copy of the Pre-operative Checklist is discussed and completed by the operating room nursing staff, with the admission area staff member, in holding bay. This clinical handover of the patient, prior to transfer into the anaesthetic bay is to include the patient in the discussion where possible.

Marking of the surgical site (when appropriate) also takes place in the holding bay. It is performed by a member of the surgical team who will be involved in the procedure: an arrow is placed at or near the surgical site with an indelible pen and initialled by the

surgical team member it should be placed so that it remains visible after draping.

Step 1 Check-inThe check-in process is undertaken by the anaesthetic nurse and/or anaesthetist in the anaesthetic bay, or procedure room, prior to anaesthesia where they: confirm the patient’s identity, procedure, site and consent with the patient confirm the anaesthesia safety check and attaching pulse oximetry perform the airway assessment check for drug allergies.

Step 2 and 3 Team Time Out and Check Out (performed electronically in the operating room)These two steps are performed by the operating team, which comprises of surgeons, anaesthesia professionals, nurses, technicians and other operating room personnel all of whom play a role in ensuring the safety and success of an operation. During the SSC briefings, all team members must pause, listen and participate by providing a verbal response to other team members. However, it is the surgeon or surgical registrar performing the surgery that is the designated SSC co-ordinator and is responsible for confirming that the team has completed each task before safe surgery commences.

In emergency circumstances this step may be skipped. Emergency treatment is defined as ”Treatment that is immediately necessary to save the person’s life or prevent a serious deterioration in their condition is considered an emergency and can be provided without consent, providing there is no pre-existing written directive by the patient or their substitute decision maker to the contrary”. For further information please refer to the CHHS Consent and Treatment Policy 2016.

The SSC is completed electronically within the Clinical Portal (see Attachment 1) and on completion is sent electronically to the Clinical Records Information System (CRIS).

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Some responses in both steps of the electronic SCC may prompt additional information in a free text response. For example if “yes” is ticked in the anaesthetic concerns box, a box drops down for the anaesthetist to document their specific concerns in relation to anesthetising the patient e.g. identifying potential difficulty in intubating the patient.

Escalation for non-compliance with this PolicyNon-compliance with this Policy may be identified immediately or later via compliance reports.

At the time of surgery, if any staff member has a concern that the surgical safety checklist is not being followed as per policy, they are in the first instance to voice their concerns to the other members of the operating team and surgery must not proceed.

In the event that surgery proceeds, non-adherence to policy must be immediately reported as an incident to the Clinical Nurse Consultant/Nursing Team Leader who will escalate to the Peri-operative Assistant Director of Nursing (ADON), who is responsible for investigating the incident.

Medical staff must report the incident to the Clinical Director of Surgery directly or the Peri-operative ADON.

A Riskman is to be completed by the person witnessing the incident.

Compliance reports are provided to the Division of Surgery based on data from the Clinical Portal and ACTPAS. If a clinician is identified as having repeatedly breached policy requirements, the following process for non-compliance is to be followed: meet with Clinical Director and Executive Director of Surgery and Oral Health (SOH) to

address non-compliance with this Policy, and if a medical officer continues not to comply with policy, further action will be taken in

accordance with the ACT Public Sector Medical Practitioners Enterprise Agreement 2013-2017 or Visiting Medical Officers Service Contract 2016.

Monitoring compliance with the SSC Compliance reports are prepared by the Clinical Safety and Quality Unit and drawn from data from the Clinical Portal SSC electronic form, completed in the operating room and relevant fields from ACTPAS. Assessment for compliance is against several defined breach categories designed to ensure compliance with the correct process.

Observational audits (five per week) of the Surgical Safety Checklist team briefing are performed by the Division of Surgery.

These reports are provided to Clinical Governance Executive, through Standard 5 Patient Identification and Procedure Matching and the Clinical Director of Surgery.

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Purpose

The purpose of this Policy is to address clinical care and patient safety risks associated with surgical procedures by mandating all CHHS staff adhere to the correct process for completing the CHHS SSC.

The completion of the SSC will improve: surgical safety and reduce both the mortality rates and the incidence of surgical

complications. This will prevent procedures being performed on the wrong patient or body part resulting in death or major permanent loss of function

matching of the patient to the correct procedure, and communication within the surgical team and between the patient and the surgical team.

Scope

This policy applies to all invasive and non-invasive procedures performed in CHHS operating rooms.

This document applies to the following CHHS staff working within their scope of practice: surgical and anaesthetic medical staff nursing and midwifery staff students under direct supervision, and all other staff employed in the operating room environment e.g. wardsperson,

radiographers.

Roles & Responsibilities

The surgeon or surgical registrar is responsible for: initiating and leading SSC briefings while the patient is in the operating room reading aloud discussion points on the SSC form providing a verbal response to discussion points raised relevant to the role, and completion of the SSC form by checking a tick box relevant to each discussion point.

The operating team comprises of: surgeon and surgical assistants anaesthetists/anaesthetic registrar scrub and scout nurses, and anaesthetic nurses.

The operating team is responsible for participating in, and performing the SSC.

The Perioperative ADON, the Director of Nursing (DON) SOH, the Clinical Director of Surgery, the Director of Anaesthesia and the Executive Director SOH are the governing bodies responsible for ensuring the Surgical Safety Checklist is completed appropriately.

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Related Policies, Procedures, Guidelines and Legislation

Policies ACT Health Directorate Nursing and Midwifery Continuing Competence Policy Consent and Treatment Policy Patient Identification and Procedure Matching Policy ACT Health Incident Management Policy

Procedures Patient Identification and Procedure Matching Procedure ACT Health Incident Management Procedure ACT Health Significant Incident Procedure

Legislation Health Records (Privacy and Access) Act 1997 Human Rights Act 2004

References

1. World Health Organisation: http://www.who.int/patientsafety/safesurgery/ss_checklist/en/

2. NSW Government Health: Clinical Procedure Safety: http://www0.health.nsw.gov.au/policies/pd/2014/pdf/PD2014_036.pdf

Search Terms

Surgical Safety Checklist, Electronic, Peri operative, Operating theatre

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Attachments

Attachment 1 – CHHS Surgical Safety Checklist

Disclaimer: This document has been developed by ACT Health, Canberra Hospital and Health Services specifically for its own use. Use of this document and any reliance on the information contained therein by any third party is at his or her own risk and Health Directorate assumes no responsibility whatsoever.

Date Amended Section Amended Approved ByEg: 17 August 2014 Section 1 ED/CHHSPC Chair

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Attachment 1 – CHHS Surgical Safety Checklist

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