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Improving the quality of administration of the Surgical Safety Checklist: a mixed methods study in New Zealand hospitals
  1. Jennifer M Weller1,2,
  2. Tanisha Jowsey1,
  3. Carmen Skilton1,
  4. Derryn A Gargiulo3,4,
  5. Oleg N Medvedev1,
  6. Ian Civil5,6,
  7. Jacqueline A Hannam,
  8. Simon J Mitchell2,3,
  9. Jane Torrie2,3,
  10. Alan F Merry2,3
  1. 1 Centre for Medical and Health Sciences Education, University of Auckland, Auckland, New Zealand
  2. 2 Department of Anesthesia and Perioperative Medicine, Auckland City Hospital, Auckland, New Zealand
  3. 3 Department of Anaesthesiology, University of Auckland, Auckland, New Zealand
  4. 4 School of Pharmacy, University of Auckland, Auckland, New Zealand
  5. 5 Division of Surgery, Auckland City Hospital, Auckland, New Zealand
  6. 6 Department of Surgery, University of Auckland, Auckland, New Zealand
  1. Correspondence to Professor Jennifer M Weller; j.weller{at}


While the WHO Surgical Safety Checklist (the Checklist) can improve patient outcomes, variable administration can erode benefits. We sought to understand and improve how operating room (OR) staff use the Checklist. Our specific aims were to: determine if OR staff can discriminate between good and poor quality of Checklist administration using a validated audit tool (WHOBARS); to determine reliability and accuracy of WHOBARS self-ratings; determine the influence of demographic variables on ratings and explore OR staff attitudes to Checklist administration.

Design Mixed methods study using WHOBARS ratings of surgical cases by OR staff and two independent observers, thematic analysis of staff interviews.

Participants OR staff in three New Zealand hospitals.

Outcome measures Reliability of WHOBARS for self-audit; staff attitudes to Checklist administration.

Results Analysis of scores (243 participants, 2 observers, 59 cases) supported tool reliability, with 87% of WHOBARS score variance attributable to differences in Checklist administration between cases. Self-ratings were significantly higher than observer ratings, with some differences between professional groups but error variance from all raters was less than 10%. Key interview themes (33 interviewees) were: Team culture and embedding the Checklist, Information transfer and obstacles, Raising concerns and ‘A tick-box exercise’. Interviewees felt the Checklist could promote teamwork and a safety culture, particularly enabling speaking up. Senior staff were of key importance in setting the appropriate tone.

Conclusions The WHOBARS tool could be useful for self-audit and quality improvement as OR staff can reliably discriminate between good and poor Checklist administration. OR staff self-ratings were lenient compared with external observers suggesting the value of external audit for benchmarking. Small differences between ratings from professional groups underpin the value of including all members of the team in scoring. We identified factors explaining staff perceptions of the Checklist that should inform quality improvement interventions.

  • surgery
  • checklists
  • patient safety
  • quality improvement
  • evaluation methodology
  • human factors

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  • Contributors JW, TJ, IC, JAH, SJM, JT and AM designed the study. TJ, DAG and CS collected the data. JW, TJ, JAH, CS and ONM analysed the data. JW, TJ and ONM drafted the manuscript. All authors contributed to subsequent iterations and approved the final manuscript.

  • Funding This study was funded by a grant from the Australian and New Zealand College of Anaesthetists.

  • Competing interests JW has previously been employed on a project funded by the New Zealand Health Quality & Safety Commission (HQSC) to train surgical staff in the use and audit of the WHO Surgical Safety Checklist. AFM is Chair of the New Zealand HQSC Ian Civil is Chair of the Safer Surgery Program, administered by the HQSC. The HQSC is a government funded independent organisation which has led a national programme to implement the Checklist in New Zealand.

  • Patient consent Not required.

  • Ethics approval This study was approved by the authors’ institutional ethics committee and locality approval was obtained for each study site; University of Auckland Human Participants Ethics Committee (ref: UOA016558).

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data sharing statement We are not participating in data sharing due to ethical reasons. However, extra data are available for peer review purposes by emailing Dr Oleg Medvedev; email:

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