Results from 85 anaesthetists were analysed. Only 25 % regularly used the pre-anaesthetic surgical checklist, with the main reason for non-use being that it was not available. Other reasons included because the anaesthetists thought it was not clear, or too long, or they chose to ignore it.
The minimum requirements for safe anaesthesia practice include the presence of a trained provider with adequate skills, appropriate anaesthesia monitors, disposables and drugs and relevant management protocols for each level of care [12]. In 1999, the Institute of Medicine estimated that medical errors account for up to 98,000 deaths each year in the United States [13]. Failures in teamwork and communication account for 70 % of sentinel events in obstetrics [14]. Strategies to reduce errors and subsequent adverse outcomes have therefore focused on team and individual training, including simulations and drills, development of protocols, guidelines and checklists, use of information technology, and education.
Because checklists help to identify and correct preventable errors and omissions before problems arise, they are an essential step in reducing the number of adverse events by standardizing work processes. These checklists have to be tailored to the local context, and be as comprehensive as possible, but also short and clear [15]. This conclusion is supported by a 2014 systematic review of the effect of the World Health Organization surgical safety checklist on postoperative complications. Adherence to aspects of care embedded in the checklist was associated with a reduction in postoperative complications [16].
Anaesthetists are accustomed to checklists in theatre, the best known being the anaesthetic machine checklist. Safety checklists are also available for other situations, including on the ward, in the ICU (intensive care unit), and in the operating theatre. While seemingly simplistic, the evidence suggests that patients benefit from well-designed checklists used effectively. Effective implementation requires training, coaching, and a change in safety culture, with routine measurement and regular feedback of outcomes [10].
While our results may seem unusual, and specific to implementation in low and middle-income countries, a Dutch study reported that participants used the checklist only 14 out of 40 times [17]. Providers indicated that it was not used either because they did not know that there was a checklist or were already aware that the contents of the list were complete so found it unnecessary to (double) check. This study identified many of the difficulties in increasing use of checklists in the healthcare sector. A Swiss study reported a small but significant benefit when using a printed checklist as a memory tool during the sign-out process, the proportion of interventions with almost all validated items being higher than those without the memory tool (20 % vs. 0 %) [18].
Recent publications from other centres have confirmed that the sustained use of the WHO checklist improves communication and ensures the reliability of routine interventions such as antibiotic prophylaxis and thromboembolic prophylaxis [19, 20]. Although the evidence suggests that standardization of care improves patient safety, it cannot be assumed that implementation of the SSC will automatically lead to a reduction in complications. A large before–after study showed that obligatory use of the checklist was not followed by a significant effect on postoperative mortality or complication rates in Canada [21]. Studies in lower-income countries, however, have shown more marked results of using a checklist. A Tunisian study suggested that 60 % of adverse events were preventable [22]. The importance of checklist use in clinical practice is also seen in work done by a critical care specialist in Baltimore, using a checklist of steps that doctors were required to take to avoid spreading infections. It included items such as ‘wash your hands with soap’. The results of checklist use were dramatic, including a reduction in infection rate, with 43 infections avoided, eight deaths prevented and 2 million dollars saved in one hospital alone [23]. This further explains why checklists might enhance safety in hospitals.
We found that the use of the WHO SSC was very low at the study sites even though 58 % of the respondents knew about it. The response “It is not available” is perhaps a reflection of the culture and attitudes in these hospitals rather than an indication of the actual availability. It may reflect a lack of enthusiasm for checklist use because it can actually be accessed online. With the right motivation, anyone in the medical facility can print out and pin up the checklist in theatres as a reminder to the surgical team to go through each of the components for each patient. Of more concern, we noted the absence of coordinators and a perception that using the checklist may increase workload, which means that providers may be less willing to implement it, and to an extent ignore it. We believe our findings are valid, because these low-income country hospitals are faced with several other challenges, including high patient load and low resources for anaesthesia and surgery. It is, however, imperative that they use the WHO checklist, so that preventable errors are eliminated. It is essential to make sure that healthcare professionals use the checklist, and the ‘why’ and ‘how’ should therefore be communicated effectively [24].
The strengths of this study are that it was conducted at the main referral hospitals across the region, which also double as teaching hospitals for Makerere University (Uganda), Nairobi University (Kenya), Muhimbili University of Health and Allied Services (Tanzania), National University of Rwanda and University of Burundi. Anaesthetists and other theatre staff train in these hospitals, and then work across the region. Any improvements made here would therefore be spread further. Our recommendations are generalizable to all of the countries that participated in the study. We acknowledge that this study is limited by the fact that it was a cross-sectional survey of only five hospitals, which were purposively selected as representing main referral hospitals in the East African Community countries. This could have introduced a degree of selection bias, but individual anaesthetists were selected by simple random sampling.
We recommend that the health leadership in these countries is engaged and used as advocates to encourage implementation of the WHO SSC. They will need to issue directives, urging all hospitals to implement the checklist. The quality improvement systems in the hospitals need to sensitize all members of the surgical team to the evidence on improved surgical outcomes with use of the WHO SSC, and draw up a strategic plan to operationalise its implementation. This could include training anaesthetists and other members of the surgical team on why and how, and building a team of local champions to coordinate and implement its use. To address the perception of increased work, the WHO SSC could be pinned up in all theatres as a memory tool for the surgical team to use, without having to write anything down.
Our study only focused on the knowledge and attitudes towards the use of the WHO SCC among anaesthetists. Further studies are needed to ensure the checklist is available to other members of the surgical team, and to compare attitudes to and knowledge about its use across the team.
