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Implementation and evaluation of nationwide scale‐up of the Surgical Safety Checklist

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M. C. White, K. Randall, N. F.E. Capo-Chichi, F. Sodogas, S. Quenum, K. Wright, K. L. Close, S. Russ, N. Sevdalis, A. J. M. Leather

Original languageSpanish
Pages (from-to)e91-e102
Number of pages12
JournalBritish Journal of Surgery
Issue number2
Early online date8 Jan 2019
Accepted/In press1 Oct 2018
E-pub ahead of print8 Jan 2019
PublishedJan 2019


King's Authors


BACKGROUND: The WHO Surgical Safety Checklist improves surgical outcomes, but evidence and theoretical frameworks for successful implementation in low-income countries remain lacking. Based on previous research in Madagascar, a nationwide checklist implementation in Benin was designed and evaluated longitudinally. METHODS: This study had a longitudinal embedded mixed-methods design. The well validated Consolidated Framework for Implementation Research (CFIR) was used to structure the approach and evaluate the implementation. Thirty-six hospitals received 3-day multidisciplinary training and 4-month follow-up. Seventeen hospitals were sampled purposively for evaluation at 12-18 months. The primary outcome was sustainability of checklist use at 12-18 months measured by questionnaire. Secondary outcomes were CFIR-derived implementation outcomes, measured using the WHO Behaviourally Anchored Rating Scale (WHOBARS), safety questionnaires and focus groups. RESULTS: At 12-18 months, 86·0 per cent of participants (86 of 100) reported checklist use compared with 31·1 per cent (169 of 543) before training and 88·8 per cent (158 of 178) at 4 months. There was high-fidelity use (median WHOBARS score 5·0 of 7; use of basic safety processes ranged from 85·0 to 99·0 per cent), and high penetration shown by a significant improvement in hospital safety culture (adapted Human Factors Attitude Questionnaire scores of 76·7, 81·1 and 82·2 per cent before, and at 4 and 12-18 months after training respectively; P < 0·001). Acceptability, adoption, appropriateness and feasibility scored 9·6-9·8 of 10. This approach incorporated 31 of 36 CFIR implementation constructs successfully. CONCLUSION: This study shows successfully sustained nationwide checklist implementation using a validated implementation framework.

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