Table 2 Themes and categories with illustrative participant quotes and observation notes (in italics)

Perceived usefullness

Lack of practical utility

Anaesthesiologist: Before I anaesthetise the patient, I know all the parameters for my patients, I check their circulation, and I know about their vascular occlusions and specific arterial stenosis, and I feel I have complete control of the patient, so …. It is hard to think that the checklist will provide extra safety for me.

Anaesthesiologist: Patient safety is part of our training as anaesthesiologists from the very beginning! Eh- check of the anaesthesia machine, instruments, the patients, and practically checks of everything we do! Double control of every blood products provided, medications, everything! In addition to assessing the patient in person and talking to them prior to surgery. We have always performed these items; it is part of the standardised pre-operative anaesthesia assessment and preparations.

Nurse anaesthetist: The anaesthesia machine is not due to any variation, it should be checked prior to every anaesthesia. We do not admit patients into the OT unless the anaesthesia machine is OK.

Surgeon: Well, the SSC has a function, in a very simplistic way, but it does not have a proper control function, the way it is supposed to, because we have so many checks and control mechanisms incorporated. So, I don’t think that the SSC is as important to us, as to other surgical departments, which have other pre-operative assessment routines. We have so many points of assessment, where our patients are discussed and evaluated.

Perceived benefits

Operating theatre nurse: The SSC is useful as a reminder of double checks of labelling tissue samples, and to make sure the right surgical equipment is present. Surgical routines are complicated when you are a beginner …

Nurse anaesthetist: I value how the SSC may contribute in aligning the surgical and anaesthesia plan for the entire team.

Surgeon: The team introduction is a nice way to start team working; the “Time-Out” is in a way a mental team-calibration.

Modification of implementation

Review and confirmation of items

Cardiovascular perfusionist: And occasionally, I may have to call out if there is something I believe is required or something has been omitted, i.e. that the patient has low haemoglobin levels, and I need to take action. In addition, during haemodilation, I avoid infusing too much fluid in the machine. Then I tell the surgeon and anaesthesiologist what I intend to do, to make them understand what I intend to do.

Operating theatre nurse: Some surgeons that are more reluctant than others, they just start to mumble through the SSC as soon as they enter the OT, and then proclaim to have performed time-out. Then, it is required from an OT nurse to be determined and speak up, and say, «no, this is not good enough! Everybody needs to know what you just said! » Sometimes I have to add: «No, this was not loud enough, you have to repeat the SSC! » However, to speak up requires some years of work experience.

Operating theatre nurse: I think the SSC is a good thing, but I miss team concentration during its performance Things have improved, from the beginning until now, but there is still too much disturbance during SSC performance. I really miss that everybody stops and pays attention. Due to the workflow in the OT, there is always someone who pursuits some kind of work, and does not stop. In addition, you need to pay full attention for the SSC to be advantageous.

Nurse anaesthetist: But it is obvious, the SSC performance is totally depending on the physicians participation. As soon as they became more involved, both performance and compliance increased.

Presence of team members

Nurse anaesthetist: Personally, I prefer to perform the sign-in with the anaesthesiologist being present in the OT, I think it is embarrassing to repeat the questions and items I have asked the patient previously, upon arrival in the OT. So I have almost stopped to ask the patients about their potential allergies, and so on. The anaesthetist repeats everything when they arrive in OT anyway.

Observation: The team compositions varied during the different parts of the SSC performance; The nurse anaesthetist, operating theatre nurse and anaesthesiologist were present during “Sign-In”. The nurse anaesthetist, operating theatre nurse, surgeon(s) and anaesthesiologist (occasionally) were present during “Time-Out”. The nurse anaesthetist, operating theatre nurse, surgeon(s) and anaesthesiologist (occasionally) were present during “Sign-Out”.

Barriers of performance

Nurse anaesthetist: Well, you don’t want a conflict within the OT, you’re in a way a bit tired of that, so you try once more to perform the SSC, and if you do not receive any attention, you just let it go and tick off the box, even though it has not been performed.

Nurse anaesthetist: It is so important to keep the SSC short, because it does in a way disturb our workflow.. You are about to start induction of anaesthesia, and then; «No, no, we have to stop and perform the SSC! » Our workflow is interrupted, and it is very disturbing and frustrating.

Operating theatre nurse: The anaesthesia team is responsible for the anaesthesia, medications …. It is their responsibility. Questioning them about this is like questioning them whether they have done their job or not. … .

Registration practices

Observation: At the surgical units in hospital 2, SSC performance was ticked off either after “Sign-In”, or the “Time-Out” part. There was only one box that needed to be ticked off electronically, in order for the SSC to be registered as performed. At the surgical unit at hospital 1, all three parts of the checklist had to be ticked off as three separate boxes in order for the SSC to be registered as performed.

Communication outside of the checklist

Patient specific risk communication

Anaesthesiologist: In general, we have contact with the cardiovascular perfusionist prior to surgery, to inform them about patient specific details such as medications, because they don’t read the patient records the same way we do.

Operating theatre nurse: …. And if bleeding is involved, we need to notify the anaesthesia team about the estimations of blood volume collected in the surgical suction, before other fluids are added.

Selected communication of risks

Cardiovascular perfusionist: … and these preparations are being discussed between the surgeon and the cardiovascular perfusionist prior to surgery.

Operating theatre nurse: In most cases, we have direct communication with the anaesthesiologist during induction of anaesthesia, and ask permission to start our preparations, such as positioning the patient, or inserting the urinary tract catheter.

Anaesthesiologist: … and then, the surgeons talk about the details of the surgery they have performed, while rushing out of the OT, right? And then you have to talk with them afterwards anyway, due to potential considerations post-operatively, like the follow-up antibiotic prophylaxis. Then you have to initiate contact anyway, because certain things require a follow-up.