ABSTRACT
Aim
The aim of the study is to determine the effect of the use of safe surgery checklists on team communication using the meta-analysis method.
Materials and Methods
The study utilised Google Scholar, Medline, PubMed, the National Thesis Centre, ScienceDirect, and the Tekirdağ Namık Kemal University Library catalogue and databases. Research studies published between 2009 and 2023 in Turkish or English, including postgraduate theses, national or international peer-reviewed journals, and national books, were included in the study. The following keywords were used to search for studies: “safe surgery“, “safe surgery checklist”, “checklist”, “team communication” in English and Turkish. According to the latest search conducted on 10 March 2023, a total of 172 research results were found. A meta-analysis was performed on 5 studies that met our research criteria.
Results
As a result of the meta-analysis of the five included articles, the studies were found to have a homogeneous structure. The five studies included in the meta-analysis, which evaluated the effect of using safe surgery checklists on team communication, were research articles published between 2011 and 2020. The mean effect size, expressed as the odds ratio, was positive (+1.806). The odds ratio for the effect of safe surgery checklists on team communication was 1.806 (95% confidence interval: 1.357-2.402; p<0.001), indicating a statistically significant effect.
Conclusion
It was found that surgical teams using safe surgery checklists could have 1.8 times more effective team communication compared to those not using them.
INTRODUCTION
According to World Health Organization (WHO) data, 234 million surgical procedures are performed worldwide each year. Approximately 7 million patients are affected by complications related to surgical procedures each year. The WHO states that half of the complications arising from surgical procedures are preventable. The WHO has been put forward the “Safe Surgery Saves Lives” Project in 2008. The project aims to reduce the number of surgical deaths worldwide1-3.
The checklist is a simple and useful tool designed to ensure that surgical teams act in a timely, consistent, and effective manner before, during, and after surgery. This tool aims to improve the performance of surgical teams to provide greater benefits to patients. Operating rooms are stressful environments where time is of the essence and complex procedures are performed. It is crucial that all members of the surgical team working in this complex environment coordinate their efforts. Safe surgery checklists are an important tool for ensuring this coordination, improving team communication, and preventing situations that may threaten patient safety. At this point, it is important to emphasize the team communication and awareness of the surgical team regarding the safe surgery checklist4, 5. Surgical team communication is vital due to the complexity and risks of surgical procedures. Research shows that team communication directly affects surgical outcomes6. Transparent and effective communication among team members contributes to each individual clearly understanding their roles and responsibilities. This helps surgical operations to be coordinated more effectively and reduces the risk of errors. Furthermore, internal team communication is necessary for dealing with unexpected situations and making immediate decisions7.
In this context, the study was conducted to determine the effect of the use of safe surgery checklists on team communication using the meta-analysis method.
MATERIALS AND METHOD
This study was analysed using meta-analysis methods, and a comprehensive and systematic literature review approach was adopted. Due to the use of a literature review format, no ethical committee approval was required for the study, as it did not involve any direct intervention, effect, or experiment on animals or humans.
Protocol and Registration
The study protocol is registered with PROSPERO (registration number: CRD42024518217). The study was reviewed in accordance with the PRISMA guideline for systematic reviews and meta-analyses.
Search Strategy
The study utilised Google Scholar, Medline, PubMed, the National Thesis Centre, ScienceDirect, and the Tekirdağ Namık Kemal University Library Catalogue and databases. The study included postgraduate theses published in English or Turkish between 2009 and 2023, articles published in national or international peer-reviewed journals, and studies related to the subject included in national books. The following keywords were used to search for studies: “safe surgery”, “safe surgery checklist”, “checklist”, “team communication” in English and Turkish. According to the latest search conducted on 10 March 2023, a total of 172 research results were found. The total sample size of the studies examined in the meta-analysis is 1,507, with sample sizes ranging from 96 to 747. The average sample size was calculated as 301. A meta-analysis was performed with 5 studies that met our research criteria. The study included 1 study published in 2011, 1 study published in 2012, 1 study published in 2016, and 2 studies published in 2020.
Inclusion and Exclusion Criteria
Full-text studies published in English and Turkish between 2009 and 2023, employing quantitative research methodology and examining the effect of safe surgery checklists on team communication, were included.
Qualitative studies and reviews that did not contain quantitative data, as well as studies for which the statistical data required for meta-analysis could not be obtained, were excluded.
Study Selection
A total of 172 studies examining the impact of the use of Safe Surgery Checklists on team communication were identified. After removing duplicates (32), 58 studies for which full texts were not accessible, 56 studies lacking quantitative data on team communication, and 21 studies published in languages other than English and Turkish were evaluated by two independent reviewers according to the inclusion and exclusion criteria. The study was conducted with 5 research articles (Figure 1).
Methodological Quality Assessment
Following the review of the articles, the Joanna Briggs Institute MAStARI Critical Appraisal Tool was used for five publications adapted into Turkish by Nahcivan and Seçginli8 for Descriptive/Case Series studies. This tool contains a total of 9 items. During the review of each study, the fulfilment of each of the 9 features found in these forms was evaluated in detail. Where the relevant feature was fulfilled, 1 point was awarded, and where it was not fulfilled, 0 points were awarded. All articles belonging to the subgroups included in the study were reviewed independently by two researchers, and articles scoring 6 or higher in the quality assessment were considered high quality. Inter-coder agreement was found to be 81% based on the quality assessment scores, indicating a very good level of agreement between coders.
Statistical Analysis
The licensed software “Comprehensive Meta Analysis Academic/Non-profit Pricing (version 3)” was used for data analysis. Data from all articles meeting the inclusion criteria and selected for inclusion in the study were entered into this software, and the heterogeneity of the articles was assessed. In the heterogeneity test, the random effects model was used for group analyses with p<0.05, while the fixed effects model was used for group analyses with p>0.05. The effect sizes, study weights, 95% confidence intervals (CIs), and overall effect size of all studies were calculated. For analyses performed on binary data, the “risk ratio and odds ratio” values were used as the basis for evaluating the overall effect size. Cohen’s d coefficient was used to compare means and calculate the overall effect size. A statistical significance threshold of p<0.05 was accepted for evaluating the overall effect. The kappa statistic was used in the SPSS programme to assess inter-rater reliability.
RESULTS
Each of the five studies included in the meta-analysis, which evaluated the effect of using safe surgery checklists on team communication, is a research article and has been published in peer-reviewed journals. The total sample size of the studies examined in the meta-analysis is 1.507, with sample sizes ranging from 96 to 747. The average sample size is 301. Three of the studies included in the research are descriptive, and two are retrospective research articles. The studies were published between 2011 and 2020.
Following the review of the articles, the Joanna Briggs Institute MAStARI Critical Appraisal Tool was used for the Descriptive/Case Series studies adapted into Turkish by Nahcivan and Seçginli8 for the remaining five publications. All articles belonging to the subgroups included in the study were independently reviewed by two researchers, and articles scoring 6 or higher in the quality assessment were considered high quality. Inter-coder agreement was found to be 81% based on the quality assessment scores. The Kappa value was used to determine the degree of agreement. The Kappa value (0.81) indicated a very good level of agreement between coders (Table 1).
To assess potential publication bias, a funnel plot, Rosenthal’s Safe N method, and Orwin’s Safe N method were prepared. However, as the meta-analysis included only five studies, statistical evaluation of publication bias is limited. Therefore, publication bias could not be formally assessed, although a funnel plot was constructed for visual inspection (Figure 2).
When the Begg-Mazumdar and Egger tests were evaluated for the skewness indicators of the funnel plot, Kendall’s tau value was found to be 0.300 and the p-value was 0.462 for the Begg-Mazumdar test. The analyses revealed no skewness. Rosenthal’s fail-safe number data also supported the findings in the funnel plot (Table 2).
A heterogeneity test was applied to determine the effect of the use of safe surgery checklists on team communication in the articles included in the study. The p-value obtained from the heterogeneity test was greater than 0.05 (p=0.241>0.05) and the Q-value (0.548) was found to be less than the value corresponding to the degree of freedom [(df=4 for χ2(0.95)=0.711)]. These results indicate that the studies examined in the meta-analysis have a homogeneous structure. The Z-test calculations performed for statistical significance yielded a Z value of 3.493. The I2 statistic was calculated as 27.014%, indicating homogeneity. The effect size distribution was assessed according to the fixed-effects model (p>0.05) (Table 3).
Figure 3 shows the meta-analysis results of five studies included in the research examining the effect of using safe surgery checklists on team communication, presented as a forest plot. The mean effect size (odds ratio) was found to be (+1.806). According to this result, the effect size of the use of safe surgery checklists on team communication (G.A; 1.357-2.402; p= 0.000) was found to be statistically significant, as it exceeded the odds ratio value of +1. It was determined that surgical teams using safe surgery checklists were 1.8 times more likely to have better team communication than those not using them (95% CI).
DISCUSSION
In this systematic review and meta-analysis, data from five studies with a sample size of 1.507, in which safe surgical checklists were used, were evaluated, and the effects of using safe surgical checklists on team communication were discussed. Operating theatres are fast-paced, stressful work environments where multidisciplinary staff work, complex tasks are performed, and real-time information from patients, colleagues, and monitors must be responded to9. Effective surgical team communication is vital for establishing a reliable safety culture in operating theatres10. The use of the WHO safe surgery checklist is an established practice worldwide and contributes to patient safety and collaborative teamwork. It is also used as a standard tool for team communication during surgical procedures to encourage communication and reduce hierarchy. Challenges in communication and collaboration can arise within surgical teams; a hierarchical environment, team members not knowing each other, different communication patterns, and conflicting views on teamwork are some of the issues mentioned11. Cabral et al.10 attempted to implement a programme for the use of a safe surgery checklist in their study, conducting the study with a pre-test and post-test. They found that 30% of the 114 surgical team members used the safe surgical checklist, that communication had the highest internal consistency, and that nurses’ perception of communication increased the most from the pre-test to the post-test.
Another study evaluating whether the use of safe surgical checklists improves communication in the operating theatre investigated the benefits of preoperative briefings in cardiac surgery. It found that the number of miscommunication events in the briefing group was reduced by 50 per cent compared to the group that did not use the briefing tool12, 13.
A proven communication tool, safe surgical checklists incorporate a standardised surgical checklist to minimise human error. Communication of the checklist has been shown to reduce mortality rates by improving teamwork, the safety environment and surgical outcomes1.
The WHO reports that surgical safety checklists significantly reduce morbidity, mortality and complication rates1, 14. It is estimated that more than half of the complications occurring in hospital settings are related to surgical procedures. Therefore, safety in operating theatres is a major concern13. The surgical process is a complex procedure encompassing preoperative, intraoperative, and postoperative phases. Care is provided to the patient through multidisciplinary collaboration at every stage of the surgical process. In this multidisciplinary collaboration, team communication is paramount during transitions between surgical procedures15. Communication gaps are considered one of the main causes of preventable adverse outcomes in obstetrics. A study investigating whether the use of an obstetric safe surgery checklist, based on the WHO safe surgery checklist for caesarean sections, could improve communication found that the implementation of the safe surgery checklist did improve communication16. The use of surgical safety checklists in ear, nose, and throat (ENT) and head and neck surgery procedures has been found to positively contribute to the surgical workflow in ENT and head and neck surgery and to improve the sharing of patient-related medical information among team members17. A study examining the effect of the safe surgery checklist (WHO checklist) on perioperative communication between anesthesiologists and obstetricians concluded that the implementation of the safe surgery checklist positively improved communication18. The WHO also emphasizes that the checklist should not lose its ability to influence teamwork and communication. In a study conducted by Solsky et al.19, 155 checklists were examined to investigate whether communication and teamwork were emphasized in surgical safety checklist modifications. This study concluded that increased team communication would lead to an improvement in safety culture.
As the roles of the surgical team during an operation are interdependent, effective communication between the team, including anaesthetists, nurses and surgeons, is crucial in preventing avoidable complications such as operating on the wrong area and inappropriate antibiotic use.
Study Limitations
This study aims to determine the effect of safe surgery checklists on team communication using the meta-analysis method. This meta-analysis has several limitations. First, the number of included studies is relatively small, which may limit the statistical power and generalizability of the findings. Second, despite clinical and methodological heterogeneity among the studies, a fixed-effect model was used in some subgroup analyses because the number of studies was small (n≤5) and heterogeneity tests were not statistically significant (p>0.05). Inter-study variance could not be reliably estimated using a random-effects model, which may further limit generalizability. Third, due to the limited number of studies, although funnel plots and safe N methods were created for visual inspection, publication bias could not be formally assessed. In conclusion, the limited number of studies included in the study, the fact that they were only observational and descriptive studies, differences in the use of safe surgery checklists, the limited number of studies examining only the effect on communication, cultural and clinical differences in practice, and limited reporting in some studies may affect the interpretation of the results.
CONCLUSION
The complexity of the surgical environment can lead to communication errors. This study evaluated the effect of using the safe surgery checklist on team communication in hospitals, starting from the clinic where the checklist was first implemented, using a meta-analysis method. The study included surgeons, nurses, anaesthetists, anaesthesia technicians, and surgical teams working in the surgical field. According to the analysis results, it was found that team communication was 1.8 times higher in surgical teams using safe surgical checklists than in those not using them. However, the meta-analysis was conducted with only five studies included in the study, which creates limitations and cannot be generalised. It is recommended that different studies be conducted to determine the effect of variables affecting team communication in the use of safe surgical checklists.
