Page 121 - Hospital Authority Convention 2018

Service Enhancement Presentations

F2.1 Staff Engagement and Empowerment 13:15 Room 421

Upstream Checklist before Sign-in of Surgical Safety Checklist Prevents Wrong Patient, Wrong Side and Wrong
Site Surgery
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Chan DTM , So HY , Ma CWY , Cho AWM ,3, Lee WWW ,3, Tsung PPK ,3, Cho AWM ,3, Chan FY ,2
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1 Procedural Safety Subcommittee, New Territories East Cluster, Quality and Safety Division, New Territories East Cluster, HOSPITAL AUTHORITY CONVENTION 2018
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Hospital Authority, Operation Theatre, Prince of Wales Hospital, Hong Kong
Introduction
The World Health Organization (WHO) Surgical Safety Checklist has been the standard practice in the operating rooms. In
prevention of wrong patient, wrong side and wrong site surgery, surgical pause (time-out) serves as the final and single check
before the start of surgery. However, many of the errors or irregularities originated in “upstream” steps, i.e. documentation for
consent or operation list, and making of the mark. If many of these upstream errors or irregularities are rectified before arrival
to the operation theatre, the level of safety would be increased.
Objectives
To investigate the frequency of errors or irregularities occurs in upstream processes and how an “upstream checklist” before
sign-in of Surgical Safety Checklist would prevent wrong patient, wrong side and wrong site surgery.
Methodology
Surgical Safety Checklist compliance audit was a prospective audit exercise of the institute under the stipulation of the
procedure safety subcommittee of the Quality and Safety committee. The audit was reviewed every six months since its
establishment in 2011. We would review the audit from 1 January 2012 to 31 December 2016. Up-stream non-compliance
items were classified into incomplete/inaccurate consent, inaccurate marking, incoherence in consent and operation list,
wrong laterality in both consent and operation list, and incomplete checklist were the upstream events. The severity of Monday, 7 May 2018
the event was referred to hazard analysis of the Failure Mode and Effects Analysis (FMEA) performed at the design of the
checklist.

Results
We retrospectively reviewed the Surgical Safety Checklist compliance audit from 1 January 2012 to 31 December 2016.
There were 128 events among a total of 54,553 operations (0.23%). There were 22 events of checklist non-compliance.
After excluding the checklist non-compliance, there were 106 up-stream events (0.194%). There were 36 (0.066%)
events of incomplete/inaccurate consent and 14 (0.026%) events of inaccurate marking. Also there were 38 (0.07%)
events of incoherence in consent and operation list. There were 18 major risk events of wrong laterality in both consent
and operation list (0.033%). There was no occurrence of wrong side and wrong site surgery during the study period.

Most of the errors or irregularities occurred in the up-stream processes of documentation and marking. Our results showed
86% (106/128) of the irregularities can be rectified by using an upstream checklist (before sign-in). These would have been left
undetected even with the use of WHO Surgical Safety Checklist because all the subsequent downstream checks were based
on these documentations (consent and operation list). Upstream checklist before sign-in of Surgical Safety Checklist would
rectify many of these errors or irregularities. This added redundancy would prevent wrong patient, wrong side and wrong site
surgery.

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