Safe surgery checklist: filling adherence, inconsistencies, and challenges

to identify adherence to the safe surgery checklist from its filling out in a general referral hospital in the interior of Minas Gerais state, as well as to verify factors associated with its use.

this is a retrospective, documentary, cross-sectional study with a quantitative approach. Data collection was performed through a retrospective review of medical records of patients undergoing surgery within one year. Patients of all specialties, aged 18 years or older, and with hospitalization period equal to or greater than 24 hours were included. The probabilistic sample was composed of 423 cases.

the checklist was present in 95% of the medical records. However, only 67.4% of them were completely filled out. The presence of the checklist in the medical record was significantly associated with the anesthetic risk of the patient. There was no difference in the filling out percentage among the three checklist moments: before anesthetic induction (sign in), before surgical incision (time out or surgical pause), and before the patient leaves the operating room (sign out). There were also no significant differences regarding the filling out percentage of the surgeon's responsibility items. Considering the surgical procedure performed, inconsistencies were found in the laterality item.

despite the high percentage of medical records with checklist, the presence of incompleteness and inconsistency may compromise the expected results in the safety of the surgical patient.