Table 1

Addressing known challenges in course design

Identified challenge6 8 10–12 How it was addressed
Perceptions of checklist and patient safety
  • Concerns about time and efficiency

  • Perceived importance

  • Scepticism regarding evidence base

  • Demonstration of the checklist by the teaching team to address concerns about time consumption

  • Extensive presentation of the evidence based on the initial lecture portion and offering of paper copies of the original research articles to participants

Workflow adjustments
Individual and team workflow adjustments needed
  • Multidisciplinary simulation and discussion to address concerns of workflow interruption

  • Participants themselves playing different roles in simulation to encourage teamwork for minimal workflow interruption

The checklist
  • Ambiguous questions

  • Execution did not merge with existing processes

  • Psychological ownership

Extensive, in-depth group discussion and adaptation by the hospital team to eliminate ambiguous questions, duplication and encourage buy-in and ownership
The implementation process
  • Lack of sufficient training

  • Unclear guidelines

  • Surgeons’ commitment

  • Ensuring skills such as counting needles, sponges and instruments were taught

  • Inviting entire surgical teams and asking for mandatory attendance, as well as deferring of non-emergency cases encouraged all operating room team members to participate in the training.

  • Group discussions regarding ‘who’ instigates the checklist were ensured

  • Attendance of surgeons and hospital leadership expected; dinner out with key leadership on the second night, to give them an opportunity to ask questions or clarify things in a small, informal setting

The local context
  • Executive leadership

  • Organisational culture

  • Communication and teamwork

  • Lack of necessary supplies and equipment rendering the questions useless

  • Collaboration with government and local providers during the project design and implementation phase of the programme

  • Invitation and collaboration with hospital directors and regional ministers of health for the initial presentation of evidence to ensure buy-in and ongoing support after team departure

  • General public acknowledgement by the teaching team that change is difficult, and there may be resistance; however, patient safety is in the hands of the entire operating room team

  • Donation of pulse oximeters when needed; adaptation of other questions to hospital-specific equipment