Table 5

Themes describing the challenges to checklist implementation

ThemeSolutions discussedParticipant quotes
Emergency surgery
  • Participants at many sites felt that the checklist takes too long, and the time taken puts the patient at risk

  • Another hospital observed the opposite, that taking the time even in an emergency is critical and important

  • When the checklist becomes habitual, appropriate implementation takes less than 1 min per section, so commitment to usage until it becomes habit is recommended

  • In cases of massive haemorrhage, for example, focus first on the patient

  • It’s just another administrative task that takes time while the patient might be deteriorating. (H3).

  • An emergency is actually the most important time to use the checklist, as that is when you are more likely to forget things. (H6).

Lack of personnel
Operating rooms do not have enough personnel in the room to do the checklist
  • A large checklist posted on the wall so sterile team members could read it without breaking sterility will overcome this challenge

  • Anaesthesia providers could help with noting the numbers of materials on the count sheets to maintain sterility

  • The checklist is hung up on the wall so it becomes much more easier to do. (H6)

  • All the teams communicate and help each other. (H7)

Unwillingness to change
A general sense of it being difficult to change bad habits and convincing people who were ‘set in their ways’
  • Discussion with hospital leadership and senior medical staff to determine reasons for non-use and develop protocols, and continued follow-up is needed to encourage continued adherence to protocols

  • Recommend ongoing follow-up with the Ministry of Health to make checklist use mandatory across the country for every surgery and positive or negative reinforcements as appropriate from the senior level.

  • We would like to use the checklist, but our surgeon won’t let us. (H2)

  • Habits of experienced staff are difficult to change. (H5)