Perceptions of Patient Safety Among Middle Managers at an Operating Suite

Abstract

In 2008, the World Health Organization launched the Surgical Safety Checklist (SSC) to reduce the number of adverse events occurring at operating suites. The objective of this study was to explore middle managers’ experiences of patient safety culture, the meanings they attach to this culture, and their perceptions of one of its best-known strategies, the SSC.

This study used a qualitative design involving structured interviews with the head of department, quality managers, and nursing supervisors at an operating suite. Eleven middle managers acknowledged that the SSC supports memory and instils accountability. Work overload was highlighted as the main barrier in SSC implementation, while feedback was identified as the main facilitator. We found significant differences in levels of understanding of patient safety culture among different types of middle managers and professions. Key aspects for promoting an effective, long-lasting patient safety culture were also identified.

Keywords

Patient safety program evaluation checklist quality of healthcare public health policy

Introduction

The Spanish National Health System defines patient safety as an essential component of quality care, which involves developing strategies to reduce unnecessary harm to patients during healthcare delivery (Ministerio de Sanidad, Servicios Sociales e Igualdad [Spanish Ministry of Health, Social Services and Equality], 2016).

Even at the micro-management level, middle managers are responsible for leading safety strategies and fostering patient safety culture in clinical units. They are thus responsible for putting effective implementation strategies in place (Rocco & Garrido, 2017).

There is no widespread consensus as to the definition of patient safety culture, but it has been characterised as a prerequisite for preventing and minimising patient safety incidents and learning from mistakes to reduce their reoccurrence (Ministerio de Sanidad, Servicios Sociales e Igualdad [Spanish Ministry of Health, Social Services and Equality], 2016; Weiser et al., 2008). Patient safety culture has proven to be a key indicator in avoiding these incidents. A unit can be considered to have a patient safety culture when it measures quality with indicators such as numbers of readmissions, uses clinical practice guidelines, keeps accurate records in the form of a protocol, and evaluates its effectiveness with tools such as the Surgical Safety Checklist (SSC) (Zingiryan et al., 2017). This checklist was launched by the WHO in 2008 as part of the Safe Surgery Saves Lives programme and consists of 20 items on teamwork, communication, adherence to good practices, and pre-empting unwanted effects. Its success is linked to its participatory nature, as it promotes shared accountability (Ministerio de Sanidad y Política Social [Spanish Ministry of Health and Social Policy], 2009; World Health Organization, 2008).

The SSC, one of the best-known patient safety tools, includes strategies for implementation, as well as for continuous evaluation to maintain its effectiveness. The tool encourages professionals to engage in a range of behaviours that are influenced by both barriers (e.g., lack of time, excessive length, perception of duplication of other tools) and facilitators (e.g., SSC training, feedback, and adaptations) (Dharampal et al., 2016; Fourcade et al., 2012; Russ et al., 2014).

These barriers and facilitators have been studied among the surgical care team itself, but rarely among middle managers (Gillespie et al., 2016). A recent study by Berry et al. (2018) found that in hospitals where the SSC had been introduced, senior and middle managers were more participatory and engaged more with the training activities and team meetings scheduled by the hospitals (Berry et al., 2018).

The objective of this study was to explore middle managers’ experiences of patient safety culture and the meanings they attach to this culture. Specifically, the aim is to explore perceptions of the elements comprising this type of culture among professionals who can be a driving force behind the changes required to ensure patient safety in surgical settings: patient safety, patient safety culture, and barriers and facilitators to the implementation of the SSC.

This study is part of a broader evaluation of the implementation of the SSC in a tertiary care hospital.

Materials and Methods

Study Design

This study used a qualitative design involving structured interviews conducted with middle managers at an operating suite at a general university hospital.

San Pedro Hospital in Logroño, Spain, is a tertiary care hospital with a total of 630 beds, which is publicly funded and has the largest hospital capacity in the region of La Rioja. According to a 2018 report, 81.38% of the 5,842 surgical procedures requiring hospitalisation performed were distributed among four departments, representing a significant gap with respect to the rest of the departments: trauma surgery (1,695 procedures), general surgery (1,315 procedures), urological surgery (1,128 procedures), and obstetric and gynaecological surgery (616 procedures).

The participants in the study were middle managers in the departments with the highest number of surgical procedures. The sample was multi-professional in nature. An intentional sampling method was used. The criteria for inclusion were as follows: belonging to one of the four departments mentioned and being a head of department, quality manager, or nursing supervisor.

To conduct the interviews, a thematic script was designed (Figure 1) based on the Cuestionario de Cultura de Seguridad del Paciente (Spanish Patient Safety Culture Questionnaire), an adaptation of the Hospital Survey on Patient Safety, by the Spanish Ministry of Health, Social Services, and Equality, and the University of Murcia (Ministerio de Sanidad y Consumo [Spanish Ministry of Health and Consumers], 2005). The interviews were conducted by the principal investigator in the locations and on the dates agreed with the participants. The interviews were conducted from October 2019 to January 2020, in Spanish, face to face, in the offices preferred by the interviewees. The privacy and anonymity of the interviewees were preserved at all times. Each interview began with an introduction and explanation of the purpose of the research, after which participants were asked to give their consent in writing. The interviews were recorded by the researcher, who used a field notebook to collect non-verbal aspects of the meetings and take pre-analytical notes.

Figure 1.

Thematic Script for the Semi-structured Interviews.

The interviews were transcribed for analysis by a professional transcriber. All transcripts were audited for accuracy by the same interviewer who conducted the interviews. For data analysis, first, ART and APM identified the categories, themes, and sub-themes in the interviews based on the research objectives and previous studies. Second, FRS, ISA, and TSS familiarised themselves with the interviews and notes to thoroughly understand the discourses. Third, the whole research team carried out the categorisation process by consensus. Categories were not created on a line-by-line basis, but rather by highlighting relevant issues that reflected the research questions (Graneheim & Lundman, 2004; Vaismoradi et al., 2013). LMS, ART and APM prepared the first draft of this article, which was revised by the whole research team. The analytical process was conducted entirely manually, using software only for data storage.

The study was approved by the Health Research Ethics Committee at La Rioja regional government, Spain. The quality of the study was ensured by following the COnsolidated criteria for REporting Qualitative research (COREQ) checklist (Tong et al., 2007). The confidentiality of the data and the anonymity of the participants were preserved in compliance with the Spanish Organic Law 3/2018, of the 5 December, on Personal Data Protection and Guarantee of Digital Rights (Ley Orgánica 3/2018, de 5 de diciembre, de Protección de Datos Personales y garantía de los derechos digitales), as well as in compliance with the Spanish Royal Decree (RD 1720/2007). Informed consent to disseminate anonymised data was obtained from the participants. The quotes used to illustrate the results in the manuscript have been anonymised and grouped by category. For additional data or quotes, please contact the corresponding author directly.

Results

Eleven interviews were conducted with middle managers and leaders of SSC implementation at San Pedro Hospital. The duration of the interviews ranged from 30 to 60 minutes. Table 1 summarises the characteristics of the interviewees.

Table 1.

Characteristics of the Participants.

Department	Number of Participants
Nursing Department (n = 3)	Assistant nurse coordinator at the operating suite (n = 1)
Nursing Department (n = 3)	Operating room nurse supervisors (n = 2)
Anaesthesiology Department (n = 1)	Quality manager (n = 1)
Trauma Surgery Department (n = 2)	Head of department (n = 1)
Trauma Surgery Department (n = 2)	Quality manager (n = 1)
General Surgery Department (n = 3)	Head of department (n = 1)
	Quality manager (n = 1)
	SSC manager (n = 1)
Urological Surgery Department (n = 1)	Quality manager (n = 1)
Obstetric and Gynaecological Surgery Department (n = 1)	Quality manager (n = 1)

The themes and related sub-themes have been summarised based on the thematic script for the interview (Figure 1).

Patient Safety

When asked about the meaning of the term ‘patient safety’, the participants gave a wide range of definitions, most of which included the words ‘mistakes’ and ‘avoidable’ or ‘foreseeable incidents’. Some participants used practical examples to define the concept, such as protocolising procedures or establishing good communication between professionals and between professionals and patients.

Safety is a concept that encompasses practically everything: doing things right, making sure that a patient is always comfortable, anything related or leading to a correct diagnosis, a correct treatment, correct information. It’s a very broad concept. (P1, General Surgery Department)

Participants recount experiences using adjectives such as ‘fundamental’, ‘basic’, ‘primordial’, and even ‘vital’.

[Patient safety is something] vital, primordial, particularly in inpatient care and surgery, of course. (P7, Urological Surgery Department)

Interestingly, one of the interviewees mentioned the need to define the concept of patient safety as a defence mechanism for professionals, because ‘one cannot rely’ on what has been written on the subject. ‘You must make sure you know the patient first-hand’ (P11, Nursing Department).

Patient Safety Culture

Despite being a widespread concept in this setting, when participants were asked what they understood by patient safety culture, two of them stated that they had no words to clearly describe it. Their descriptions were very generic and alluded to the characteristics of the concept, rather than to the concept itself: ‘forming habits’, ‘something in everyday life’, ‘involvement’, ‘awareness’, ‘incorporating it into care’. Some participants associated patient safety culture with empathy, while others considered it a value or belief.

Empathising with patients so that you treat them as you would yourself or a close relative. (P9, Nursing Department)

Professionals [should] believe in patient safety. (P1, General Surgery Department)

However, professionals reported noticing a greater involvement in patient safety on the part of the hospital’s directors in recent years.

A number of steps have recently been taken by the quality committees, and a range of measures are being implemented. Most importantly, there is a quality protocol for use with surgery patients. (P7, Urological Surgery Department)

[The hospital directors] are taking some steps, but I still think we should do more, uh.… I mean, it’s something that has improved, but there’s still a lot more to be done. (P3, General Surgery Department)

[It takes] the [hospital] directors’ insistence and personal commitment to make this happen. (P8, Obstetric and Gynaecological Surgery Department)

Overall, we have identified three stances describing professionals’ involvement: there is no patient safety culture among professionals at present; there is, but it can be improved; and there is corporatist behaviour among nursing professionals, who assume that they are the only group of professionals with a patient safety culture.

[There’s a patient safety culture] among nurses, yes, but among other professionals, I sometimes doubt it. (P10, Nursing Department)

[There’s no patient safety culture] in La Rioja because we’re creatures of habit and this had never been done until now. (P4, Anaesthesiology Department)

I think there’s starting to be [a patient safety culture].… I don’t think there has ever been one in my department, nor has there been one in general. So, and this is just my opinion, [I believe] that in the past year … two years … we’ve started to instil this culture, to promote change. (P5, Trauma Surgery Department)

Barriers and Facilitators

We identified an exhaustive list of barriers to the implementation of patient safety culture and of the SSC in particular. Only one participant denied the existence of barriers. In half of the interviews, ‘resistance to change’ emerged as one of the main elements hindering the implementation of these strategies. Table 2 illustrates these barriers with quotes from participants.

Table 2.

List of Barriers Identified.

Resistance to change	[This is] the way of thinking: ‘I’m doing fine doing it this way, so there’s no need to fix it, my outcomes are good’ (P2, General Surgery Department)‘Many people see it as something extra to do [on top of everything else] and don’t see the benefits they can obtain from it, so it’s something new that’s difficult to integrate [into our daily work], just as it’s difficult for us all to integrate other things into our lives’. (P4, Anaesthesiology Department)‘They’re not convinced that this will serve any purpose. These are people who have usually been working for a long time, people with more experience and since they’ve never done that before.’ (P7, Urological Surgery Department) ‘They won’t change their minds [about the SSC] until the day one of the things we’ve gone over fails … or until the day one of them has surgery and we ask him if he wants us to use it or not. I mean, I think that often you get carried away by the general dynamic. You introduce it in a service and it gets used, eventually. At the end of the day, ideally, one should be convinced [of the usefulness of the SSC], but the important thing is that it gets used’. (P10, Nursing Department)
Work overload/lack of time	‘The operating time that we often have, which is very short, depends a lot on other specialties or departments, even on the cleaning service, on the porter.… It’s often difficult [to change] the culture because people see it as something extra, a waste of time.’ (P4, Anaesthesiology Department)‘Well, time, it’s the lack of time … I think the main [reason] is the lack of time.’ (P6, Trauma Surgery Department)‘No, not at all, I mean, it just takes a minute, not at all, no … I am convinced that it’s not because of [lack of time], that’s for sure … it’s just because … no. That’s all’. (P5, Trauma Surgery Department)
Demotivation	‘Lack of motivation. I mean, the [patient safety] culture is there, but it takes an effort to do it, so there may be some people who don’t feel motivated, who don’t want to put it into practice’. (P2, General Surgery Department)‘Well, everyone should be made aware of how important it is, everyone should become aware and cooperate, because if some of us are using it and always doing all the donkey work, at the end of the day, either through neglect or because you get tired of doing all the donkey work, then you eventually stop using it.’ (P11, Nursing Department)
Abandonment of projects	‘[it’s not just a matter of] starting a project and then abandoning it … but [a matter of] persevering’. (P3, General Surgery Department)
Lack of established roles	‘Let’s see who uses it, I mean, the fact that it’s not clear who’s responsible for using it is a barrier, and, of course, there’s this question: ‘why does it have to be me?’ I mean, the question of who’s [responsible for] filling it out is another barrier, I mean, it’s great, but who will be [responsible for] filling it out?’ (P4, Anaesthesiology Department)‘Established roles, [I mean, everyone says] that’s not my job, [but it’s also] not theirs or someone else’s, and nobody does it. When you talk about it with other people individually, they end up saying ‘let someone else do it’. (P7, Urological Surgery Department)

In the participants’ discourses, facilitators are closely linked to barriers. Most of the interviewees agreed on essential facilitators, such as training and feedback. With regard to their perspective as middle managers, different managerial attitudes toward facilitation are observed: ‘raising awareness’ and ‘holding team members accountable’, along with ‘forcing’ and ‘insisting’. Table 3 shows a summary of the facilitators identified.

Table 3.

List of Facilitators Identified.

Feedback/regular meetings	‘Discussing outcomes, which is rare. I believe that when you set something in motion and you discuss outcomes, well, you motivate people … or demotivate them, but it’s not actually demotivating, because things can be brought back on track.’ (P3, General Surgery Department)‘The little feedback I’ve been able to get from people, because it’s been two years that I’ve been away and, at the end of the day, all this.’ (P9, Nursing Department)‘You can’t see the outcomes, and so people, well, of course, if you avoid exactly that.’ (P10, Nursing Department)‘Positive reinforcement in small groups and then report these results every three months’. (P4, Anaesthesiology Department) ‘I believe that it’s perseverance, everyone’s perseverance, which is needed’. (P8, Obstetric and Gynaecological Surgery Department)
Further training	‘I think we should place more emphasis on training professionals, on training [them] in the use of tools such as the checklist or tools that help create a protocol for all procedures’. (P3, General Surgery Department)‘What to do, I mean, [what to do] for small groups, I mean, by department, because it goes without saying that the operating suite encompasses many different things’. (P4, Anaesthesiology Department)
Leaders/quality committee	‘Perhaps on a voluntary basis … by a number of members who will be trained in this and pass on some of their knowledge’. (P1, General Surgery Department)‘Maybe quality managers, maybe those who are more directly responsible for quality [could] arrange regular meetings, well, inform us about the outcomes obtained, well … about how the rate of completion [of the checklist] is going, erm … and regularly report on safety and why it is important.… Maybe putting a little bit more pressure on the … the departments, even if it is a little bit of a nuisance, well, they could come down every two or three months and discuss all that with us … remind us that [safety] is important.’, (P4, Anaesthesiology Department)
Evidence-based/protocolised healthcare	‘All the procedures we perform on patients must be evidence-based and we must rely on studies to determine which actions should be taken according to a protocol’. (P2, General Surgery Department)‘The minute the checklist is made into a protocol and put in place it’ll run on its own and everyone will use it.… The main problem is [getting people to] change’. (P7, Urological Surgery Department)
Role models	‘[People should] see how others work in other well-known hospitals and in other large [healthcare] centres and their outcomes’. (P2, General Surgery Department)‘By informing them that it’s really being used and that, well, it’s in their best interests. When people see that the whole department and the rest of the departments are using it, it seems that it’s easier for people to catch the wave and start using it than if [only] I use it but nobody else does, isn’t it?’ (P5, Trauma Surgery Department)
Support from managers	‘If there’s someone in charge and you see them as someone close to you, who’s not asking you to do anything that they wouldn’t do themselves, I think that helps. I mean, at the end of the day, erm … at the end of the day, anyone superior becomes a sort of mirror in which we see ourselves’. (P9, Nursing Department)‘Projects and programmes that are sponsored by directors and superiors must be set in motion so that the rest of the [workers in] the department or in any other hospital knows that this is indeed positive’. (P2, General Surgery Department)
Social acceptance	‘It’s like inertia, so it takes a lot to overcome it. The people who aren’t aware of it must be made aware of it by osmosis, so to speak, by those who are aware. So it’s a very slow process, but it’s professionals themselves who have to spread the word and raise awareness among others’. (P1, General Surgery Department)

The Surgical Safety Checklist

With respect to the SSC, participants are clearly aware of its structure, which includes a series of questions relating to the safety of surgical procedures that aim to minimise errors and unnecessary delays.

[The SSC contains] a series of items you have to fill in to try and minimise all the factors, erm … that can lead to errors. To minimise the possibility of all these factors being overlooked. I mean, to try, as far as we possibly can, not to make any foreseeable errors. (P3, General Surgery Department)

So, the physician and the patient, they answer a series of questions in the presence of the anaesthetist to check and be 100% sure that the basics, such as [blood] cross-matching and antibiotics, are correct, and that, if the patient is to be operated on the right leg, [he or she] will be operated on the right leg. (P6, Trauma Surgery Department)

[The SSC is] a survey that you use to make sure that you have the surgical equipment ready, the anaesthetist’s ventilator ready, in other words, that it’s all systems go. (P4, Anaesthesiology Department)

Nine of the 11 participants felt that the SSC was important and necessary, although two of them stated that it depended on the situation and that the SSC could even pose a greater risk if used inadequately. As for the meanings attached to the SSC, we found discourses related to the objectification of the surgical procedure so that no aspect of it is neglected at a time when the dynamics of the operating theatre can result in everyone being completely immersed in their own tasks. In this sense, the SSC also favours co-accountability among team members.

We’re very busy every day, we see so many patients, so many surgeries are performed.… You’re often completely focused on the patient, but other times, well, I mean, you have a lot of work to do, you have other things on your mind and, well, you have to try to have an objective way of, well, not overlooking any of the most relevant data. (P2, General Surgery Department)

I think that the SSC is a safety measure that, let’s say, is cheap, accessible to everyone, easy, prevents and mitigates damage, encourages everyone’s accountability and co-accountability, promotes teamwork, and favours continuity of care. I mean, as well as allowing all this, it does so in a cheap and efficient way. (P3, General Surgery Department)

All participants mentioned co-accountability of the whole team, although there were some nuanced discourses about accountability and coordination. It seems that most professionals understand that it is nurses who should coordinate the SSC due to their position within the surgical setting, although this does not mean that accountability for patient safety lies entirely with nurses.

The procedure must be divided between three professionals, that is, the physician, the anaesthetist, and the nurse. Who should coordinate it? Only one person, mind you! There is a greater consensus that it should be the nurse, because [he or she] is considered to be the one who can do it best. That doesn’t mean that he or she is the one held accountable, because sometimes we are mistaking the person who coordinates it for the person accountable, but that’s not the case here. (P3, General Surgery Department)

The implementation strategies identified in the interviews were closely related to the facilitators described in Table 3. Among the suggestions for improvement, mandatory implementation of the SSC emerges as one of the prerequisites for its proper use in most of the discourses.

I think that little by little everyone will be convinced that it’s something that should be compulsory. Actually, it’s quite unthinkable not to do it, because they’re using it in many leading centres. There’s no reason for us to change that dynamic. (P2, General Surgery Department)

To me, it is something that has to be compulsory, without half-measures, especially when it comes to the checklist. (P7, Urological Surgery Department)

I find this study very interesting for analysing compliance [with the SSC]. I believe that compliance has to be close to 100%. And the non-compliance rates per department should be analysed to get a sense of what it might be … because it should be a compulsory thing. Just like pilots do before flying, we should do the same before operating. This culture has to be incorporated. (P8, Obstetric and Gynaecologic Surgery Department)

Another suggestion that emerged in a number of the discourses concerned the use of the tool itself and the analysis of its structure and function. In this respect, several interviewees suggested the need to eliminate some items because they considered them to be unnecessary:

Yes, I believe so. At first, of course, it was a little hard to introduce because we thought, ‘If circulating nurses are filling out their own sheet, why do we have to fill this out too?’ Well, there’s that, because it was like performing two tasks that, okay, [helped] to improve things, but they could be merged into one. Mind you, we’ve already said this too. It’s something that we’ll probably end up doing in the long run, because it’s a bit absurd. You register the time of entry [on one form] and you document the time of entry on the other; you register if [the patient] has allergies [on one form] and you register if [the patient] has allergies on the other. At the end of the day, it’s duplicating things a bit. (P11, Nursing Department)

Discussion

The objective of this study was to explore the experiences and perceptions found among middle managers in a multidisciplinary team at an operating suite in a tertiary care hospital in relation to the following aspects: patient safety; patient safety culture and barriers and facilitators to implementation; and the SSC and recommendations for its improvement.

This study made it possible for middle managers to reflect on a strategy (the SSC), which they use but had not previously analysed, despite the role that research on this subject attributes to these professionals with regard to its implementation (Berry et al., 2018).

We found similarities between our study and other studies regarding the increasing need for strategies to promote patient safety culture and effectively develop patient safety tools. Tartaglia Reis et al. (2018) conducted a systematic review of the characteristics of the Hospital Survey on Patient Safety Culture in several primary, secondary, and tertiary care hospitals in 21 countries. The authors showed that these hospitals had a weak patient safety culture overall. Specifically, they needed to reinforce strategies aimed at training professionals, preventing loss of important patient information, and promoting teamwork between units in order to prevent fragmentation of care and the culture of blame (Saturno, 2009; Tartaglia Reis et al., 2018). All these needs were also identified in our study.

A number of studies refer to supervisory actions and teamwork as strengths, which is reflected in our results. It is worth noting that the word ‘team’ was hardly mentioned in the discourses, despite operating suites being among the units with the highest levels of interdependence between professionals (Fujita et al., 2019; Plaza et al., 2017; Rönnberg et al., 2015).

Numerous studies report on professionals’ opinions of patient safety strategies, including avoiding abandoning projects, as the results show. It should be stressed that, although our study included middle managers only, the conclusions we reached were very similar to those of previous studies, suggesting that the study sample is representative. Among the barriers to the implementation of a patient safety culture and related strategies, such as the SSC, participants mentioned resistance to change, lack of time or work overload, demotivation, abandonment of projects, and clinicians themselves. These barriers are also reflected in other studies (Russ et al., 2014). To enhance patient safety culture, the following measures were suggested: providing constant feedback and outcomes, offering further training, establishing patient safety leaders, promoting the Quality Committee, holding regular meetings, delivering evidence-based and protocolised healthcare, having role models and support from managers, and promoting social acceptance (Mella Laborde et al., 2018).

A comprehensive understanding of the barriers and facilitators relating to the implementation of patient safety strategies helps to assess their feasibility and the outcomes that are obtained through them. This can be achieved by controlling for the constantly interacting factors in each setting (Carvalho et al., 2015; Conley et al., 2011; Etherington et al., 2019; Gillespie et al., 2017).

Considered by all professionals as an essential tool (provided it is used properly), the SSC is the most widely used patient safety strategy in the surgical setting and there is a growing consensus as to the suitability of its use (Cullati et al., 2014). The interviewees suggested two important measures to make the SSC more effective: making it mandatory and removing information duplicated on other records.

Qualitative studies on middle managers’ perceptions of these concepts in the context of an operating suite and from a multidisciplinary perspective are scarce, lacking in depth, and do not adopt a multicentre approach (Carvalho et al., 2015). The qualitative research methods used in these patient safety assessments can help to explain why interventions work or do not work, explore the factors influencing their effectiveness, and ascertain whether there is an adequate flow of communication between the professionals in the multidisciplinary surgical team and their middle managers (Giménez-Júlvez et al., 2017; Russ et al., 2014).

The main limitations of this study relate to the non-inclusion of all surgery departments. The surgery departments under study were selected using convenience sampling. Bias may also have been introduced in the information collected from the interviews, since not all of the planned interviews were conducted. Three interviews did not go ahead because some heads of surgery departments refused to collaborate. Moreover, qualitative studies do not seek to generalise the results obtained, but to gain an in-depth understanding of the phenomenon under study. As a result, the applicability of this research is limited to settings similar to the one described here.

We deemed it necessary to analyse the aforementioned concepts from the perspective of middle managers, as they play a key role in generating positive outcomes among other professionals. In a systematic review of qualitative studies on the subject, Bergs et al. (2015) highlighted the need for leaders responsible for implementing the SSC to work on removing barriers and enabling facilitating factors. A purely technical approach to the checklist does not foster cooperation between surgery, anaesthesiology, and nursing professionals; there is a need for figures to serve as leaders in implementing and promoting use of the SSC.

Footnotes

Acknowledgements

We would like to thank the Regional Ministry of Health in La Rioja, Spain, and the directors of San Pedro Hospital for their collaboration, with special thanks to the directors of the Operating Suite and the Nursing Department.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship and/or publication of this article.

Ethical Approval

The study was approved by the Health Research Ethics Committee at La Rioja regional government, Spain.

Funding

The authors received no financial support for the research, authorship and/or publication of this article.

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