Aim of the present study was to describe the status quo of the WHO-surgical checklist use in Switzerland after a national media campaign to promote checklist use in OR routine. Differences between three groups that were exposed differently to core aspects of the national media campaign were analysed. Use of other checklists than the WHO-surgical checklist was not assessed, because the national media campaign explicitly promoted the WHO-surgical checklist, as it is most commonly used today and most thoroughly studied. To date, the WHO-surgical checklist is widely used in Switzerland. Almost two thirds of the participants (63.2 %) report that they use the WHO-surgical checklist at their current workplace. Also, more than 90 % of the participants report that they are familiar with the WHO-surgical checklist. In 2012, only about 25 % of the participants reported using the WHO-surgical checklist . Although this comparison is not based on repeated measures, it clearly indicates a more prominent use of the WHO-surgical checklist in Switzerland today. Results also show that individuals use the checklist frequently. 85 % of the participants report using the checklist in more than 90 % of the procedures. Checklist use also seems to be quite established today, as about 70 % of the participants report that they use the checklist at least since 2 years. The results reflect that for a majority of the participants use of the surgical checklist has become a professional standard. However, although checklist use seems to be widely established, still 37 % do not use the checklist. And of those who do, the checklist is still not used in 100 % of the procedures. These results clearly show that although surgical checklist use is widespread in Switzerland, room for improvement remains. As checklist use has shown to reduce morbidity and mortality only if compliance is high, systematic use still needs further promotion in Switzerland even today.
In a second step we analysed differences between initiative-participants, hospital staff and attending physicians with regard to attitudes, intentions to use the checklist and reported ease of use. Differences between groups were not confounded by profession (nurses and doctoral staff) as one might assume. Although overall effects were very small, significant differences especially between attending physicians and the two other groups emerged. Results reflected a generally more positive attitude, greater acceptance, and stronger intention to use the checklist in hospital staff and initiative-participants than in attending physicians. Also, hospital staff and initiative-participants reported significantly greater ease of use than attending physicians. Interestingly, no significant differences emerged for the reported value of checklist use for the patient. Although attending physicians evaluate the use of the checklist as less important and less pleasant, they nevertheless acknowledge the overall benefit for the patient. The results indicate that the checklist seems to be accepted as a useful tool for patient safety in surgery across all HCPs. However, actual using the checklist and accompanying behavioural aspects were less established and less positively evaluated in attending physicians than in initiative-participants or hospital staff. The same was true for general attitudes and the intention to use the checklist. Here, again, initiative-participants and hospital staff reported significantly more positive attitudes towards the checklist and a stronger intention to use the checklist than attending physicians. Taken together, one may conclude that although the overall evaluation of the benefit of the checklist for patients is similar across groups, initiative-participants and hospital staff report more positive attitudes and greater ease of use. Maybe due to the greater exposure to situations with checklist use, initiative-participants as well as hospital staff also report significantly more often than attending physicians that they witnessed the prevention of an adverse event due to checklist use. The prevention of an adverse event might be one factor that additionally influenced the attitude of hospital-staff and initiative-participants in comparison to attending physicians. Witnessing the prevention of an adverse event might be most influential for future checklist use. Interestingly, the only difference that emerged for the question concerning whether or not patient safety was more focussed on today than a year ago emerged between initiative-participants and hospital staff. Initiative-participants reported significantly more often that patient safety received more attention than year ago. This might be due to the fact that participation in the initiative was resource intensive for individuals, hence, patient safety in surgery as a topic was very present throughout initiative duration.
This study has several limitations. First, generalizability of the findings is limited. Although for doctoral staff, all members of the professional associations of invasive HCPs and for nursing staff, two large professional associations were addressed; the response rate of about 25 % limits the significance of the results. Additionally, for nursing staff, members of a third relevant professional association could not be addressed for data protection reasons. Quantitatively, the response rate is in accordance with other studies in health care , however, we cannot rule out sampling bias or response bias as no information about non-responders were available. Second, results are not based on repeated measurement. Hence, although we discuss development of checklist use in Switzerland, no real inferences can be made. Although unlikely, we cannot rule out the fact, that in a worst case scenario differences are due to sample composition alone and not to development in checklist use. Third, no causal inferences about the impact of the national media campaign on checklist use can be made. Although differences found in the data point into the direction hypothesized, it is not warranted to causally assign them to the national media campaign. Other influences as well as systematic differences between groups that were not assessed could be alternative explanations of the results. Fourth, overall effects are very small. Hence, although differences between groups exist statistically, practical relevance is limited.