Patient Safety Culture Around Surgical Safety Checklist Use in High-Pressure Operating Rooms

Abstract

Background: Surgical Safety Checklists are widely used to reduce preventable perioperative harm, but their effectiveness depends on the safety culture in which they are performed. In high-pressure operating rooms, urgency, hierarchy, turnover demands, interruptions, and professional assumptions may reduce checklist use to documentation rather than meaningful communication. Objective: This study aimed to explore how patient safety culture shapes meaningful use of the Surgical Safety Checklist in high-pressure operating-room contexts. Methods: A qualitative interpretivist design was used. Semi-structured interview data from 12 multidisciplinary operating-room participants representing surgical, anaesthetic, nursing, and theatre leadership perspectives were analysed using reflexive thematic analysis. The analysis focused on checklist meaning, time pressure, hierarchy, psychological safety, local adaptation, ownership, near misses, and organisational learning. Results: Five themes were developed: checklist as cultural conversation; time pressure and ritualised compliance; hierarchy, voice, and psychological safety; adaptation, ownership, and local fit; and learning culture after near misses. Checklist use became meaningful when it created shared attention, enabled multidisciplinary voice, preserved core safety checks while allowing local relevance, and linked concerns to visible improvement. It became ritualised when pressure, hierarchy, poor participation, or weak feedback reduced it to form completion. Conclusion: Surgical Safety Checklist governance should move beyond narrow compliance monitoring toward socio-cultural safety practice supported by senior role modelling, protected checklist time, psychological safety, disciplined adaptation, and non-punitive learning.