Checklists can be great tools, but how do you bring a laminated piece of paper that hangs on the wall to life so that it's a critical part of every case? We asked the team at Saint Peter's University Hospital in New Brunswick, N.J., for the keys to their success.

First things first. Don't reinvent the wheel. Visit the World Health Organization (osmag.net/fQMc9R) or AORN (osmag.net/Mnn6QQ), where you'll find tools to help your facility frame out a checklist. A boilerplate checklist is a good place to start, but you'll want to customize it by adding and subtracting elements to fit your needs, says Beverly Johnson, MSN, RN, CNOR, the perioperative instructor at Saint Peter's.

Let each department help create and implement the checklist, she says. Enlist the help of surgeons, anesthesiologists and nurses to make sure you've covered all aspects of patient care, including wound classification, confirming sterilization indicators, establishing a sharps safe zone before each case and all phases of antibiotic administration, from pre-op to just before the first incision is made. Anesthesia looked at steps that addressed airway concerns and availability of equipment, blood loss, medication checks, status of the pulse oximeter, the type of anesthesia to be administered and fire risk assessment. It also added a time out before the administration of anesthesia.

If you're thinking that some of these steps may not seem like patient safety issues, you're not alone. Saint Peter's debated whether each aspect needed to be in the checklist.

"At first we weren't sure that a sharps safe zone check needed to be in the checklist since we usually consider this a staff safety issue," says Roseann DiBrienza, MS, RN, NE-BC, director of perioperative services. "But if a nurse or surgeon suffers a sharps injury, then it absolutely can affect patient safety."

The checklist is divided into 4 parts:

• Pre-procedure check-in. The circulating nurse confirms patient information and both the RN and the anesthesiologist assess the patient for anesthesia concerns.
• Prior to anesthesia induction. The circulating nurse confirms patient information with the anesthesiologist and makes sure all risks are accounted for before the patient is induced.
• Prior to incision. The circulating nurse confirms with the surgeon and anesthesiologist that all surgical team members are present for surgery and the appropriate antibiotic has been administered before the surgical incision is made.
• Prior to surgeon leaving the OR. The circulating nurse confirms that all instrument, sponge and needle counts are completed and the items are accounted for. If there were any equipment or other issues during the case, additional steps are required.

Train and revise

After compiling the feedback, they presented the checklist to the OR committee, the perioperative patient care areas, and the departments of anesthesia and surgery for approval.

"Once we had approval, we immediately began training," says Ms. DiBrienza. They developed scripts for the staff. Trainers observed staff and gave them feedback over the course of the multiple in-services.

One hurdle: Some surgeons felt the checklist took too long to complete. "We reminded them that the same thing happened when we initiated the surgical time out," says OR Manager Anna Prendergast, BSN, RN, CCRN. "There was a learning curve, but once we all found a rhythm it became a natural part of the surgical process."

They hung large posters of the checklist on the walls in each pre-op bay and OR. "They can be easily seen from anywhere in the room," says Ms. DiBrienza. Collecting the checklist after each case served as a measure of compliance.

Integrate into the EMR

The checklist evolved over time. Saint Peter's added steps for patient warming and the proper dosing and timing of antibiotics, says Ms. DiBrienza.

"But we also realized that we were just adding another piece of paper," says Ms. Johnson. "So we decided to integrate the paper checklist into our electronic records."

Their old EMR had a checkbox that asked whether the nurse had completed the paper checklist. Now they wanted the entire checklist integrated into the EMR, so the OR nurse had to check off each element.

"It had to be easy to use and navigate," says Magdalena Sayed, MSN, RN-BC, CNOR, who was tasked with integrating the safety checklist into the EMR. "I had to take the piece of paper and turn it into a live version. Everything had to be included and it all had to be searchable in case someone needed to access a piece of the checklist at any point during the perioperative process."

At first, nurses were concerned about the added mouse clicks, but just as with implementing the checklist itself, they soon overcame the learning curve and adapted to the electronic version.

Collaboration and compliance

The results have been impressive since Saint Peter's implemented its surgical safety checklist in the first quarter of 2013. "We asked our quality control department to look at our inpatient patient mortality rate before and after we started using the checklist," says Ms. DiBrienza. During the first year of implementation, their surgical mortality rate dropped from 1.44% to 0.65%. "And it's continued to trend down since then," says Ms. DiBrienza. In the third quarter of 2017, the mortality rate was 0.4%. OSM