Beyond the tick box: what makes a veterinary surgical safety checklist effective in practice?

MANY factors affect how teams function in complex, high-pressure work systems such as veterinary practice, including characteristics of the environment, equipment, tasks and people involved, as well as the overall organisation and culture of a workplace.1, 2 Adopting tools and strategies that help teams ‘get it right’ more of the time can be one way of strengthening safety and resilience in these environments.3 Checklists have become embedded within standard safety procedures in many safety critical, high risk industries, from aviation to human healthcare, for exactly this purpose: to ensure crucial steps in complex processes are not missed and to help teams do the right things, the right way, at the right time. Alongside providing cognitive prompts, checklists also shape how teams communicate essential safety information, influencing teamwork and shared situational awareness (ie, being on the same page about risks, expectations and plans).4, 5 Surgical safety checklists (SSCs) are now a cornerstone of human healthcare systems worldwide, with a substantial body of evidence demonstrating their positive impact on patient safety.6, 7 However, evidence also shows that improvements in patient safety depend not only on whether SSCs are used, but also on how they are developed, adapted and implemented within a team, as part of how people work together.6 Malucelli and Tivers found that while widespread adoption of SSCs was evident across the hospitals evaluated, their implementation varied, revealing opportunities to strengthen the effectiveness and impact of SSCs on patient safety beyond simply standardising tasks.9 Surgical safety checklists are a valuable tool to improve patient safety. However, to be effective, consideration must be given to how they can best support the teams using them, not only by prompting essential safety checks but also by optimising communication, teamwork and shared risk awareness But is all adaptation helpful? Malucelli and Tivers introduce the concept of checklist overload and the term ‘non-killer items’ – referring to checklist items that are not directly relevant to patient safety.9 Adding excessive admin-heavy tasks during local adaptation risks the checklist being perceived as a ‘to-do list’ rather than a safety process. Furthermore, alongside suboptimal structure and layout, checklist overload can add more cognitive and task demands on individuals, thereby diluting the focus on essential safety checks and improved teamwork, which were the original purpose of the checklist. It's not just what's in a checklist or the layout that's important; how they're introduced and actually used matters too. While the majority of responding hospitals in Malucelli and Tivers' study believed their SSC had a positive effect on patient safety, only 14 per cent provided checklist training for their teams, 36 per cent had a designated ‘checklist champion’ and 50 per cent conducted regular reviews and updates of their SSC.9 However, these iterative design, leadership and training features are recognised as being central to the success of any patient safety improvement intervention.12 In human healthcare, they are strongly linked to safety culture and checklist effectiveness,13 and they therefore offer opportunities to further strengthen the impact of SSCs for veterinary teams. Malucelli and Tivers found wide variation in who leads checklist completion across the hospitals they studied, with registered veterinary nurses, anaesthetists and surgeons all playing different roles at individual hospitals.9 In human healthcare, evidence shows that the person completing the checklist is less important than the consistency with which it is completed, the process of clarifying roles and the culture within which the checklist is applied.14 To make sure that checklists don't become a silent form-filling exercise, part of their implementation includes verbalising the prompts, encouraging input from all team members present to aid communication and situational awareness, both of which are essential for effective team performance.2 So, what are the implications of Malucelli and Tivers' study? While the authors reiterate that further work is needed to evaluate safety outcomes in relation to specific features of checklist design and implementation, this study highlights opportunities that could strengthen checklist effectiveness at multiple levels.9 For local surgical teams, variation in the quality of SSCs may affect their impact. Therefore, their design and balance between relevance and overload should be considered. Team engagement, culture and leadership are also vital to how SSCs are used and the likelihood of their success in perioperative safety improvement. Meanwhile, for hospital management and clinical governance leaders, this study highlights potential gaps in formalising processes and structures for SSC implementation, where designated champions, training and regular audits may have the greatest impact. Across the wider veterinary profession, awareness and enthusiasm for checklists is growing, but this could plateau unless benefits are evidenced and focus on further development is actively maintained. With a growing awareness of human factors as an approach to better understand the fit between people, the work they do and where they do it, approaching checklist development and implementation in veterinary practice through this lens may help avoid the design and usability pitfalls outlined in Malucelli and Tivers' study. In conclusion, checklists must be considered far more than mere paperwork. Effective checklists require consideration of how they can best support the teams using them, not only by prompting essential safety checks but also by optimising communication, teamwork and shared situational awareness. Malucelli and Tivers' work provides essential visibility into current practice, actionable steps for practices to consider and a platform for future work that demonstrates SSCs deliver the benefits they promise.