Development of mobile application for safe surgery checklist

the Surgical Incision and Before the Patient Leaves the Room. At the end of all the steps of the application, it calculates the risk to patient safety. The application developed is a tool that can be implemented in health institutions and used by professionals working in the operating room.


INTRODUCTION
Contemporary society consists of individuals, companies and the State operating in a local, national and international field in a structure defined as Network Ed Society. The functioning of this new social structure is dependent on digital communication and information technologies (CASTELLS; CARDOSO, 2005). After the innovation caused by the Internet, the popularization of smart phones (smartphones) is considered the most impactful technological revolution in recent years (TIBES et al., 2014;IDC, 2013).
The popularization of smartphones has changed the relationship with technology, since these devices play the function of pocket computer, since it allows a variety of possibility due to its great diversity of applications. This computer-like functionality is due to the development of advanced operating systems for smartphones . Bilotti et al. (2017) states that currently, the smartphone allows easy access to the internet at a relatively low cost. It allows access to applications that address the most varied topics, including can be an alternative to improve the population's access to health, as well as promotion and prevention.
The health area is certainly one of the most influenced by the growing use of communication and information technologies. Over the years, the use of mobile devices has grown and gained more and more space in this area, giving rise to the concept of mobile health (mHealth) defined as medical and public health practices aided by portable devices, such as mobile phones, patient monitoring devices, digital personal assistants and other wireless devices (WHO, 2011).
The applications, for the most part, are created by private developers and are not linked to needs surgery, it is essential that anesthetic and surgical procedures occur with quality and that the patient's safety culture allows possible errors to be minimized through the application of the Protocol for Safe Surgery of the World Health Organization (WHO) (CORONA; PENICHE, 2015).
Who used three principles to develop the Checklist, simplicity, wide applicability and possibility of measuring impact. It allows teams, by efficiently following critical safety steps, to minimize the most common preventable risks that endanger lives and compromise the well-being of surgical patients (ELIAS et al., 2015).
The Checklist consists of 19 items divided into three distinct moments: before anesthetic induction, before the surgical incision and before the patient leaves the operating room (OLIVEIRA et al., 2018;AMAYA et al., 2015;PAIVA et al., 2015;SORIA-ALEDO et al., 2012).
Before Anesthetic Induction: The patient is verbally confirmed with the patient the identity of the same, the procedure and the place of surgery, and whether the consent to the procedure was signed. It checks whether the correct side of the surgery has been signaled and the proper functioning of the pulse oximeter. The anesthesia team should verbally review whether the patient has difficult-to-access airways, risk of blood loss or allergic reaction (WHO, 2009). Development of mobile application for safe surgery checklist www.nucleodoconhecimento.com.br Before Starting Surgery: Professionals present themselves with name and function. Aloud, the identity of the patient, the procedure and the location of the body to be operated are checked. Later, the surgeon, anesthesiologist and the nursing team verbally review the critical points for surgery. Next, the prophylactic use of antibiotics in the last 60 minutes and the availability of imaging tests are confirmed (WHO, 2009).
Before the Patient leaves the Operating Room: Before the patient is referred to the anesthetic recovery room, the team analyzes the procedure performed, checks the amount of surgical compresses and instruments, identifies the anatomical parts, checks for possible damage to the equipment and problems to be solved, and outlines care plans in relation to the patient's postoperative period (WHO, 2009).
In the area of health the use of checklist is a relatively recent practice, however, in areas such as aviation, nuclear energy sector and civil construction is already part of the routine of the work process, because it allows the verification of important items that could be forgotten by the team. These areas use technology in the structuring and implementation of this process, a practice that could be incorporated for patient safety (FREITAS et al., 2014).
Thus, the objective of this study was to develop an application for conference and control of all stages of the Safe Surgery checklist suggested by the World Health Organization improving the safety of patients submitted to surgery.

Methods
This study is applied in the technological development of an application with the possibility of deployment in any health service and easy installation on mobile devices.
The development of the application involved a constructivist proposal and consisted of the intentional action of planning, developing and applying specific situations, incorporating mechanisms that favor contextualization.
The app was built based on the Safe Surgery checklist established by the World Health Organization. The WHO allows each institution to adapt the Safe Surgery Checklist to its reality, however, as the intention is that the application can be used in the most diverse Development of mobile application for safe surgery checklist www.nucleodoconhecimento.com.br institutions and realities, it was decided to use the standard Checklist recommended by the WHO.
The development occurred through the author's own work with a programming team. This moment comprised the definition of how checklist steps would be presented in the application, the definition of the navigation structure, the application tools, and the planning of the configuration of environments.
The mobile app is available on a website with download link on smartphone or tablet with Android operating system. After its development, the application was tested during surgical procedures in a Teaching Hospital.
The study was carried out after approval by the Ethics Committee on Research in Human Beings of Sagrado Coração university -Bauru/SP.

Results
The initial presentation of the application was developed so that the professional can insert the data regarding the procedure that will be performed. Subsequently, the questions of the WHO Safe Surgery checklist will be presented so that each stage is performed during the procedure and subsequently answered. If the step is performed correctly and the item is filled, the application automatically goes to the next step, as presented below: In the case of the stage Before anesthetic induction, in the item confirmation about the patient, application questions whether the place of surgery and the procedure to be done has been confirmed, if the professional does not respond as directed by the WHO, the application will bring an alert, stating that this attitude will entail a risk to the patient and questions whether the professional wishes to continue. If the professional responds that they want to continue, the application will move on to the next item. If the professional informs that he/she does not want to continue, the application returns to the previous screen requesting confirmation of the place of surgery and the procedure to be performed.
As long as the professional does not perform the step correctly or does not inform that he/she intends to go to the next step, even being aware of the risk to patient safety, the application will remain questioning the professional. On the screen referring to the item where the professional should question the patient about some allergy, if the answer is negative, the application will proceed to the next step. However, if the patient informs that he has some type of allergy, the professional will answer yes and the application will open a field to be informed what is the patient's allergy, be it some medication, material or food.
By finalizing the items that must be performed before anesthetic induction, the application will question the risk of difficult airway and the risk of blood loss.
Following the steps of the Safe Surgery Checklist, the questions refer to the "Before starting surgery" step. Similarly, if the answer is appropriate the application goes to the next item, if the answer is inadequate, the application alerts the professional about the risk to patient safety and if, still, it wants to continue.
At this stage, also known as time out or surgical pause, the application acts assisting professionals with all necessary questions. An application screen questions whether all team Development of mobile application for safe surgery checklist www.nucleodoconhecimento.com.br professionals confirm their names and professions, the following screen asks the surgeon, anesthesiologist and nurse to confirm the patient's identity, location and procedures to be performed. Later, surgeon, anesthesiologist and nursing are asked by the application if there is relevant information that needs to be shared. Finally, the safe surgery application questions about antibiotic prophylaxis in the last 60 minutes before the incision and the availability of imaging tests in the operating room.  There is also the print option that allows you to print the report to a configured printer or save the PDF file to your Tablet or Smartphone.

Discussion
The safe surgery application was developed considering that the health applications aimed at safe surgery served only as a consultation of the who checklist steps. The functionality of this application allows the professional to interact with all stages of the WHO checklist, promoting patient safety and encouraging professionals to correctly follow all stages.
In addition to improving communication in the operating room, the checklist is a tool to ensure patient safety. There is a difficulty in verbalizing information on the part of some professionals, so the checklist provides opportunities for professionals to share any concerns with other team members (PANCIERI et al., 2014;CUNAT et al., 2011;HAYNES et al., 2011;PAUGAM-BURTZ, GUERRERO, 2011;RATEAU et al., 2011).
In relation to the patient, three identifications were chosen: name, date of birth and mother's name. More than one identification favors patient safety and the chosen identifiers allow the patient to respond more easily. Next it is necessary to fill in the name of the surgeon and the procedure that will be performed.
The correct identification of the patient is valid and necessary so that the entire surgical team does not perform erroneous procedures. (ALPENDRE et al., 2017;FREITAS et al., 2014).
This confirmation ensures that the surgery is performed on the correct patient. Identifying the patient is essential to ensure that care is provided to the correct patient, considering the possibility of patient change. Given this possibility, the identification of the patient, according to the protocol, is recommended by the Ministry of Health for all institutions that provide health care. (AMAYA et al., 2015;MINISTÉRIO DA SAÚDE, 2013).