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Impact of the Norwegian National Patient Safety Program on implementation of the WHO Surgical Safety Checklist and on perioperative safety culture
  1. Arvid Steinar Haugen1,2,
  2. Eirik Søfteland1,3,
  3. Nick Sevdalis2,
  4. Geir Egil Eide4,
  5. Monica Wammen Nortvedt5,
  6. Charles Vincent6,
  7. Stig Harthug7,8
  1. 1Department of Anaesthesia and Intensive Care, Haukeland University Hospital, Bergen, Norway
  2. 2Center for Implementation Science, Health Service, and Population Research Department, King’s College London, London, United Kingdom
  3. 3Department of Clinical Medicine, Faculty of Medicine, University of Bergen, Bergen, Norway
  4. 4Centre for Clinical Research, Haukeland University Hospital, Bergen, Norway
  5. 5Centre for Evidence Based Practice, Western Norway University of Applied Sciences, Bergen, Vestland, Norway
  6. 6Department of Experimental Psychology, University of Oxford, London, Oxfordshire, UK
  7. 7Department of Research and Development, Haukeland University Hospital, Bergen, Norway
  8. 8Department of Clinical Science, University of Bergen, Bergen, Norway
  1. Correspondence to Dr Arvid Steinar Haugen; arvid.haugen{at}


Objectives Our primary objective was to study the impact of the Norwegian National Patient Safety Campaign and Program on Surgical Safety Checklist (SSC) implementation and on safety culture. Secondary objective was associations between SSC fidelity and safety culture. We hypothesised that the programme influenced on SSC use and operating theatre personnel’s safety culture perceptions.

Setting A longitudinal cross-sectional study was conducted in a large Norwegian tertiary teaching hospital.

Participants We invited 1754 operating theatre personnel to participate in the study, of which 920 responded to the surveys at three time points in 2009, 2010 and 2017.

Primary and secondary outcome measures Primary outcome was the results of the patient safety culture measured by the culturally adapted Norwegian version of the Hospital Survey on Patient Safety Culture. Our previously published results from 2009/2010 were compared with new data collected in 2017. Secondary outcome was correlation between SSC fidelity and safety culture. Fidelity was electronically recorded.

Results Survey response rates were 61% (349/575), 51% (292/569) and 46% (279/610) in 2009, 2010 and 2017, respectively. Eight of the 12 safety culture dimensions significantly improved over time with the largest increase being ‘Hospital managers’ support to patient safety’ from a mean score of 2.82 at baseline in 2009 to 3.15 in 2017 (mean change: 0.33, 95% CI 0.21 to 0.44). Fidelity in use of the SSC averaged 88% (26 741/30 426) in 2017. Perceptions of safety culture dimensions in 2009 and in 2017 correlated significantly though weakly with fidelity (r=0.07–0.21).

Conclusion The National Patient Safety Program, fostering engagement from trust boards, hospital managers and frontline operating theatre personnel enabled effective implementation of the SSC. As part of a wider strategic safety initiative, implementation of SSC coincided with an improved safety culture.

  • surgery
  • anaesthesia
  • healthcare quality improvement
  • patient safety
  • safety culture

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  • Contributors ASH, ES, NS and SH conceived the study. ASH collected data and performed all analysis with GEE (professor in biostatistics). MWN and CV contributed to interpretation of data. ASH drafted the manuscript and ES, NS, GEE, MWN, CV and SH revised it critically for intellectual content. All authors approved the final version to be published and agree to be accountable for all aspects of the work.

  • Funding This study received departmental support. ASH received postdoctoral grant from the Western Norwegian Regional Health Authority with grant number: HV1172. Parts of the work were carried out during a research stay at the Centre of Implementation Science, IoPPN, King’s College London, UK. NS’s research is funded by the National Institute for Health Research (NIHR) via the ‘Collaboration for Leadership in Applied Health Research and Care South London’ at King's College Hospital NHS Foundation Trust, London, UK. NS is also a member of King’s Improvement Science, which is part of the NIHR CLAHRC South London and comprises a specialist team of improvement scientists and senior researchers based at King’s College London. Its work is funded by King’s Health Partners (Guy’s and St Thomas’ NHS Foundation Trust, King’s College Hospital NHS Foundation Trust, King’s College London and South London and Maudsley NHS Foundation Trust), Guy’s and St Thomas’ Charity, the Maudsley Charity and the Health Foundation.

  • Disclaimer The views expressed are those of the authors and not necessarily those of the International Federation of Nurse Anaesthetists (IFNA), European Society of Anaesthesiologists’ (ESA) Patient Safety and Quality Committee, NHS, the NIHR or the Department of Health and Social Care. The funders had no role in the design, conduct or analysis of this study. The Norwegian Directorate of Health had no role in planning the design, conduct or analysis of this study.

  • Competing interests ASH represent the IFNA in the ESA Patient Safety and Quality Committee. NS is the Director of London Safety and Training Solutions Ltd, which provides quality and safety training and advisory services on a consultancy basis to healthcare organisation globally. The other authors report no conflicts of interest. SH had a role as lead of the Scientific Advisory Board appointed by the Norwegian Directorate of Health 2011–2013. IFNA, ESA, London Safety and Training Solutions Ltd.

  • Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.

  • Patient consent for publication Not required.

  • Ethics approval The Regional Committee for Medical and Health Research Ethics in Western Norway reviewed our study before data collection. The study was considered as quality service improvement (Ref: 2009/561) and approved by hospital managers and the privacy Ombudsman (Ref: 2010/413).

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data availability statement The raw datasets generated and/or analysed during the current study are not publicly available due data privacy rules, though anonymous data are available from the corresponding author on reasonable request.

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