August, 2016 - SUPPORT Summary of a systematic review | print this article |

Do paper-based safety checklists improve patient safety in acute hospital settings?

Safety checklists are used as tools to improve care processes and patient safety outcomes.

 

Key messages

  •  Surgical safety checklists may improve death rates and major complications within 30 days after surgery.
  •  It is uncertain whether safety checklists improve adherence to guidelines or patient safety in intensive care units, emergency departments or acute care settings.
  • Randomized trials are needed to inform decisions about the use of safety checklists in acute hospital settings.

Background

Guidance is available on how to create checklists, what should be included, and how to implement them. However, checklists are often implemented as a part of multicomponent quality improvement initiatives. It has been unclear whether checklists are effective in improving patient safety in acute care settings. To the extent that they are effective, it is unclear what checklist designs and implementation tools are most effective. It is also unclear to what extent checklists themselves contribute to the effectiveness of multicomponent interventions.

Safety checklists can be either paper-based or electronic. This summary is focused on paper-based checklists.



About the systematic review underlying this summary

About the systematic review underlying this summary

Review objectivesTo assess if the use of safety checklists, compared to not using checklists, improves patient safety in acute hospital settings

Type of What the review authors searched for What the review authors found

Study designs & interventions

Comparative studies of paper-based checklists, applied to hospitalized patients by medical care teams, compared to controls (care provided without checklists).

Before-after studies (9) that evaluated a wide variety of checklist designs and training on use of the checklists.

Participants

Medical care teams (a medical clinician or surgeon had to be included).

Medical teams.

Settings

Acute hospital settings.

Intensive care units (5 studies), emergency departments (2), surgical units (1) and multi-departmental acute care settings (1)

Outcomes

Any patient relevant clinical outcome.

Length of stay (3 studies), percentage of ventilator days on which patients received recommended care (1), time from admission until prescription of medical deep venous thrombosis prophylaxis (1), appropriate indications for use of an indwelling urinary tract catheter (1), complications during the postoperative period (1), patients receiving antibiotics within eight hours of a diagnosis of pneumonia (1).

Date of most recent search:  September 2009

Limitations: Only articles in English were included and the results of included studies were not described or analysed systematically.

Ko HC, Turner TJ, Finnigan MA. Systematic review of safety checklists for use by medical care teams in acute hospital settings--limited evidence of effectiveness. BMC Health Serv Res. 2011; 11:211  

 

Summary of findings

The review included nine before-after studies. Most studies (eight) were done in North America and one study was done in eight countries (Canada, Jordan, India, New Zealand, Philippines, Tanzania, United Kingdom and United States). Four clinical settings were covered: five studies in the intensive care unit, two studies in the emergency department, one study in surgery, and one study in multi-departmental acute care.

 

1) Intensive care unit setting

Five studies conducted in the United States evaluated checklists in the intensive care unit setting. All studies had a high risk of bias, and given the important methodological differences between them, they cannot be summarised quantitatively.

  • It is uncertain whether checklists improve adherence to recommended practice or patient outcomes in the intensive care units because the certainty of this evidence is very low.

Intensive care unit setting

People: Healthcare professionals

Settings:  Acute hospitals

Intervention: Paper-based checklists

Comparison: Care provided without checklists

Outcomes

Impact

Number of studies
Certainty of the evidence
(GRADE)

Length of stay

Different checklists were used among studies. One of the studies found a reduction in the length of stay, but the other two did not.

3

Very Low

Percentage of ventilation days on which patient received four care process (Prophylaxis of peptic ulcer disease and deep venous thrombosis, appropriate sedation and recumbent positioning.

During the period that the surgical checklist was used, the compliance in the four processes improved from 30% to 96% (p <0.001).

1

Very Low

Improvement in four domains (Use of physical therapy, transfer to telemetry, time from admission to the prescription of medical deep venous thrombosis prophylaxis, and central catheter duration)

The use of the checklist was associated with an improvement in two of the four domains.

1

Very Low

GRADE: GRADE Working Group grades of evidence (see above and last page)


 

2) Emergency department setting

Two studies evaluated checklists in the emergency department. The included studies have a high risk of bias and they could not be summarised quantitatively.

  • It is uncertain whether checklists improve adherence to recommended practice or patient outcomes in the emergency departments because the certainty of this evidence is very low.

Emergency department setting

People: Healthcare professionals

Settings:  Acute hospitals

Intervention: Paper-based checklists

Comparison: Care provided without checklists

Outcomes

Impact

Number of studies
Certainty of the evidence
(GRADE)

Length of stay.

Post-endoscopy checklist after emergency department admission was used. The study found a reduction of 50% in the length of stay during the checklist period (p=0.003).

1

Very Low

Appropriate use of catheter in patients with indwelling urinary tract catheter.

There was an increase of appropriate use of urinary tract catheters during the intervention period (from 37% to 51%; p=0.06).

1

Very Low

Documentation of an indication for a catheter in patients with indwelling urinary tract catheter.

Documentation of an indication for a catheter remained unchanged during the intervention period.

1

Very Low

 

Presence of a physician order for urinary tract catheter placement.

The presence of a physician order increased from 43% to 63% post- intervention.

1

Very Low

GRADE: GRADE Working Group grades of evidence (see above and last page)


 

3) Surgery setting

 One study conducted in eight countries (Canada, Jordan, India, New Zealand, Philippines, Tanzania, United Kingdom and United States) evaluated checklists in the surgery setting (7688 patients undergoing non-cardiac surgery).

  • Checklists may improve the death rate and major complications within the first 30 days after an operation. The certainty of this evidence is low.

Surgery setting

People: Healthcare professionals

Settings:  Acute hospitals

Intervention: Paper-based checklists

Comparison: Care provided without checklists

Outcomes Impact Number of studies
Certainty of the evidence
(GRADE)

Any major complication (including death) within the first 30 days after the operation.

The rate of death declined from 1.5% to 0.8% during the intervention period. Complications also decreased from 11% to 7%.

1

Low

GRADE: GRADE Working Group grades of evidence (see above and last page)


 

4) Acute care setting

One study conducted in the United States evaluated checklists in the surgery setting (7688 patients undergoing non-cardiac surgery).

  • It is uncertain whether checklists improve adherence to recommended practice in acute care settings because the certainty of this evidence is very low.

Acute care setting

People: Healthcare professionals

Settings:  Acute hospitals

Intervention: Paper-based checklists

Comparison: Care provided without checklists

Outcomes

Impact

Number of studies
Certainty of the evidence
(GRADE)

Proportion of patients receiving antibiotics within eight hours of a diagnosis of pneumonia.

Hospitals using a checklist administered appropriate antibiotics more often than hospitals without the checklist (OR 2.0, 95% CI not reported p=0.0005). (Forms and reminders were used in addition to the checklist.)

1

Very Low

GRADE: GRADE Working Group grades of evidence (see above and last page)

Relevance of the review for low-income countries

Findings Interpretation*
APPLICABILITY

All studies except one were conducted only in high-income countries. One study included two low-income countries and found a different magnitude of the changes in outcomes before and after the intervention across study locations.

The setting might influence the effectiveness of patient safety checklists. Those locations with good performance at baseline for the measured outcomes may have limited potential for improvements.

EQUITY

The study noted above investigated the use of checklists in more than one socio-economic and surgical setting. The authors noted no effects of income level or surgery type clusters on the outcomes.

It is possible that resource levels, staff workloads, staff training and other factors could influence the effectiveness of patient safety checklists, and that they might be less effective in disadvantaged settings.

ECONOMIC CONSIDERATIONS

The studies did not include any economic evaluations.

There may be some additional costs involved in training and educating staff on how to use checklists, as well as the time taken to use checklists. On the other hand, if they are found to improve safety, there may be savings.

MONITORING & EVALUATION

Included studies had a high risk of bias.

Randomized trials are needed to evaluate the impacts of using checklists in acute care settings.

*Judgements made by the authors of this summary, not necessarily those of the review authors, based on the findings of the review and consultation with researchers and policymakers in low-income countries. For additional details about how these judgements were made see: www.supportsummaries.org/methods


 

Additional information

Related literature

World Health Organization. Patient safety checklists. Available in http://www.who.int/patientsafety/implementation/checklists/en/

 

World Health Organization. Implementation manual WHO surgical safety checklist (first edition). Available in http://www.who.int/patientsafety/safesurgery/tools_resources/SSSL_Manual_finalJun08.pdf?ua=1.

 

Thomassen Ø, Storesund A, Søfteland E, Brattebø G. The effects of safety checklists in medicine: a systematic review. Acta Anaesthesiol Scand. 2014;58(1):5-18.

 

de Jager E, et al. Postoperative Adverse Events Inconsistently Improved by the World Health Organization Surgical Safety Checklist: A Systematic Literature Review of 25 Studies. World J Surg. 2016 Apr 28. PMID: 27125680

 

This summary was prepared by

Dimelza Osorio, Biomedical Research Institute Sant Pau - Iberoamerican Cochrane Centre, Barcelona, Spain.

 

Conflict of interest

None declared. For details, see: www.supportsummaries.org/coi

 

Acknowledgements

This summary has been peer reviewed by: Itziar Larizgoitia and Henry Ko

 

This review should be cited as

Ko HC, Turner TJ, Finnigan MA. Systematic review of safety checklists for use by medical care teams in acute hospital settings--limited evidence of effectiveness. BMC Health Serv Res. 2011; 11:211. Available at

http://www.biomedcentral.com/1472-6963/11/211.

 

The summary should be cited as

Osorio D. Do paper-based safety checklists improve patient safety in acute hospital settings? A SUPPORT Summary of a systematic review. August 2016.

www.supportsummaries.org

 

Keywords

Evidence-informed health policy, evidence-based, systematic review, health systems research, health care, low and middle-income countries, developing countries, primary health care, safety checklists, medical checklists, patient safety, pa-per-based checklists.

 



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