Mind the Gap: Reported Versus Observed Surgical Safety Checklist Time-Out Adherence in the Hybrid Operating Room

Endovascular surgery is a high-risk specialty where safety protocols are vital to prevent adverse events. Although WHO Surgical Safety Checklist (SSC) implementation showed significantly reduced overall surgical morbidity and mortality, more recent studies have shown mixed results. This study aims to observe real-world adherence to the time-out phase of the WHO SSC in a hybrid Operating Room (OR) and to evaluate the Checklist Performance Observation for ImprovemeNT (CheckPOINT) tool.

This single-center retrospective observational study of prospectively collected data included endovascular procedures performed in a hybrid OR between May 2021 and December 2022. In October 2021, paper SSCs were replaced with electronic SSCs. Procedures were recorded using the OR Black Box (Surgical Safety Technologies Inc., Toronto, Canada). Time-out evaluation of recorded procedures was performed using the CheckPOINT tool.

Time-out was initiated in 87.7% (n = 186/212) of all procedures. Average overall reported completion was 95.5% with a median of 15 completed items. Average overall observed completion was 46.8% with a median of seven items completed. Observed adherence was significantly lower than reported adherence for all but one item, "Patient Name". Experienced surgeons were significantly less likely to initiate (p = 0.033) and thoroughly complete (p < 0.001) the checklist. CheckPOINT engagement scored significantly lower than adherence, communication effectiveness, and attitude.

Video-based observation reveals significant discrepancies between observed and reported SSC adherence. These results highlight the need for improved SSC assessment and implementation, and suggest that combining reliable tools with video recording can enable data-driven quality improvement initiatives.