Experiences in the implementation of the Safe Surgery Verification Checklist at the National Hospital Arzobispo Loayza , 2014-2016

The objective was determining the experiences in the implementation of the Safe Surgery Verification Checklist (SSVC) in the National Hospital Arzobispo Loayza in period 2014-2016. The Methodology was descriptive, retrospective study of a documentary review of 2,466 clinical histories with the SSVC application sheet. It was used two instruments that evaluated the compliance of the SSVC through a control matrix to check 20 items in the three phases of execution with correct filling and omission, also a survey was applied to the personnel (Surgery, Anesthesia and Nursing). Its work in Surgical Center where the factors that limit the application of the SSVC were identified, previously assuming the respective ethical considerations. Results were compliance with the SSVC reached 93% and the most frequent noncompliance in the Entry phase referred to the risk assessment of bleeding > 500 mL (36%). In the Pause phase the item verifies the antibiotic prophylaxis administered in the last 60 minutes (39%) of the total of omissions. In the exit phase the item review the critical aspects of recovery and treatment in immediate PO (42%). The factors that limit the application of the SSVC were: Lack of staff motivation (34%), ignorance, lack of training and problems in the distribution of personnel / tasks (10% respectively). In conclusions a high level of compliance is evidenced, however, the quality of the registry shows a poor involvement of interdisciplinary responsibility, weakening the safe environment for the surgical patient.


Introduction
At present, the World Health Organization (WHO) has been making strenuous efforts so that health professionals in their daily work, get involved in working on good health practices.The services provided to the patient require a safe environment, both for the professionals themselves and for the patients, in order to avoid risks and complications in health.This implies to consider use of the measures of biosafety, rounds of safety in the hospital area and the application of the checklist among others [1].It should be noted that the WHO statistics report that there are approximately 234 million major surgery operations per year and the margin of error is between 3% and 25% of complications, which cause disabilities or prolong the hospitalization of patients withstand postoperative complications.Likewise, it is estimated that mortality rates attributable to major surgery interventions range from 0.4% to 10%, depending on the complexity of the operation and the hospital environment.According to the corresponding impact assessments, at least one million patients die each year during or after an operation, other international studies from developed countries, such as the European Commission, confirm the magnitude and significance of the problem, because the statistical information clearly reveals the high percentages of complications and deaths, in scheduled or emergency surgical interventions.In 2004, the WHO launched the "Alliance for Patient Safety" proposal, carrying out an exhaustive analysis of the world situation.It concluded the need to create safe environments, as a consequence of this exhausting situation of public health and that entails ensure the best conditions to promote actions and the application of tools and recommendations to improve patient safety worldwide [2].The study of the Ministry of Health and Social Policy of Madrid "Prevalence of adverse effects in hospitals in Latin America developed in five countries (Mexico, Peru, Argentina, Costa Rica and Colombia)", was included a sample of 11,555 patients admitted to 58 hospitals and where they indicate that the frequency of Adverse Events (AE) was 11.85% and the possibility of prevention was 60%.In addition, the AEs were related to care in 13.27%, with the use of medication in 8.23%, with nosocomial infections in 37.14%, with some procedure in 28.69% and with the diagnosis in 6.15% [3].The surgical interventions are procedures that are usually given as a practical part and involve mechanical manipulation of anatomical structures with a medical purpose, whether diagnostic, therapeutic or prognostic.Surgical procedures that require knowledge, abilities and skills, […] becoming the SSVC an essential instrument that allows the multidisciplinary team to meet quality standards to avoid and mitigate risks [4].The safe provision of health services requires a change of paradigms of health professionals, being closely linked to teamwork and the principles of values of responsibility.It should be emphasized that in order to promote safe surgical environments, it is necessary to use all the procedures of the safe surgery checklist in everyday life, as the tool that will become an opportunity for the health team, by reducing the occurrence of failures, errors, adverse results and facilitate analyzing and generating new knowledge that will help improve teamwork in this area.Hence the importance of care risk management, as an element that allows identifying the factors that contribute to the occurrence of incidents related to patient safety, as well as improving the culture of safety and identification of human and organizational factors [3,4].Some studies carried out in Peru on patient safety reveal that there is an urgent need to strengthen a safety culture in private and public healthcare institutions to guarantee the quality of services they provide to users [5,6,7].The importance of this proposed study is to evaluate the experience gained in a public institution on the implementation of the Safe Surgery Verification Checklist and identify the factors that limit its application, in order to analyze and understand the adherence behavior of the check list of safe surgery in the surgical areas and also, propose corrective measures and improvement plans that guarantee safe environments and the quality of the services offered to the patient.

Methodology
Descriptive, retrospective study of documentary review of 2,466 clinical histories with SSVC application sheet from 2014 to 2016.The study was conducted at the National Hospital Arzobispo Loayza, located in block 8 of Avenida Alfonso Ugarte, Breña, institution categorized as III-1 Level of national reference and that has 735 hospital beds of which 42% (310 beds) correspond to the surgical area.At the institutional level there are 19 operating rooms distributed in 6 surgical centers and the estimated population was obtained by counting the results obtained in the quarterly monitoring cuts distributed as follows.The SSVC format for institutional use (designed by the WHO and approved with RM No. 308-2010 / MINSA) was used as an instrument, which consists of three parts and 20 items distributed in 3 phases: Entry with 7 items (before administration of anesthesia), Pause with 8 items (before the cutaneous incision) and Exit with 5 items (before the patient leaves the operating room).An Excel format was designed which allowed recording general data such as: Clinical history number, pavilion, bed, operative diagnosis, surgery date, entry, pause, departure, coordinator, surgeon, anesthesiologist, nurse and a last column for observations.In the input, pause and exit phase, the omitted item number was registered and if it was correctly registered, a check was placed.To determine the administration of the prophylactic, the information was cross-checked between the item marking, the prescription registered in the Medical Therapy Sheet and the registration of the Nursing Kardex administration.
To measure the compliance level was calculated through the sum of items with correct answer in each format, multiplied by 100 and divided by the total number of items ( 20), this allowed obtaining the level of compliance.
Based on this result, the scale was taken into account considering a score of 91 to 100% GOOD, from 85 to 90% IN PROCESS and less than 85% TO IMPROVE.To assess the factors that influence the multidisciplinary team for the application of the SSVC was self-administered to the occupational groups of surgery, anesthesiology and nursing, respectively.

Results
The application of the Surgical Safety Checklist with a sustained progress from 90 to 95%, so it is categorized GOOD; and on the other hand an application omission is credited starting from 10% and decreasing to 5%.See Figure 1.

Table 1 .
Amount of clinical histories by years 2014 to 2016.