A BIBLIOMETRIC ANALYSIS OF THE SURGICAL SAFETY CHECKLIST: TRENDS, IMPACT AND FUTURE DIRECTIONS

The Surgical Safety Checklist (SSC) is a form-based instrument for analyzing surgical risks. This SSC is commonly used to improve patient safety and decrease surgical mistakes. This systematic review uses bibliometric analysis to provide insights about SSC trends, impacts, and future research paths. A comprehensive search of major scientific databases was conducted to discover relevant articles published between 2017 and 2022. The keywords used were connected to the Surgical Safety Checklist, and bibliometric analysis was utilized to filter papers before establishing inclusion criteria to choose the most relevant research for analysis. According to this report, there is a growing global interest in this topic. Based on bibliometric analysis, it was found that there was a growth in the number of publications related to SSC in the time period studied. These findings demonstrate the growing global interest in SSC topics as key trends in research focus, including specific aspects of checklist implementation, effectiveness, and related outcomes, have been identified. The analysis also influenced countries, institutions and leading authors contributing to the field of SSC. The systematic review discusses the impact and implications of research on SSC highlighting the positive influence of SSC in improving surgical outcomes and patient safety culture in hospitals. This review also explores emerging research directions, such as the integration of new technologies and the application of SSC in different surgical specialties. Additionally, it identifies knowledge gaps and areas requiring further research to optimize effective implementation of the SSC.


INTRODUCTION
The World Health Organization's (WHO) patient safety movement established the checklist as part of its Global Patient Safety Challenge.This Safe Surgery Saves Lives program brings together surgeons, gynecologists, anesthetists, ward and theatre nurses, infection control experts, public health personnel, patient advocates, and biomedical engineers to find potential to improve surgical care safety (White et al. 2021).Another technique to increase patient safety is to use the Surgical Safety Checklist in the pre and postoperative periods, which allows for the monitoring of predicting signs and symptoms of surgical complications and the early diagnosis of adverse events (Alpendre et al. 2017).
Process management is essential for implementing any safety project.This research addresses the complexities and problems of applying the World Health Organization surgical safety checklist, contributing to global conversations about putting policy into reality.Implications for nurse management: The efficient implementation of a checklist necessitates a coordinated management approach in partnership with team members.These approaches will facilitate learning experiences that will contribute to a shared knowledge of the change being executed by all team members (O'Brien, Graham, and Kelly 2017).
Patient safety during surgery is an important factor in the success of surgical patients.To address critical data regarding each surgical case, a surgical safety checklist is an important patient safety tool utilized by the operating room team (Mersh, Melesse, and Chekol 2021).
Despite high-quality evidence of its benefits, there have been challenges in applying the surgical safety checklist appropriately and consistently.(Brown et al. 2021).

METHOD
This study used bibliometric analysis to evaluated research of Analysis on The Surgical Safety Checklist: Trends, Impact and Future Directions.We conduct document Systematic Literature Review with Database from Scopus with search criteria were "SSC" or "Surgical Safety Checklist".Subject area of this study are medicine, nursing and health profesion.We restricted the search to articles and papers, published in English, open access and published between 2017 -2022.Papers published in 2023 were excluded.
We download data on 13 Juni 2023, resulting in 1761 document.To obtain accurate results, data preparation and cleaning were performed.We omitted data when no author information was available.A total of 1469 documents were eliminated, leaving 292 documents in the dataset.We performed data cleaning to ensure that the source, author, country, and author keywords of each document according to the inclusion criteria.To examine the data, we used Microsoft Excel 365 to generate descriptive statistics and VOSviewer software to do bibliometric analysis and graphically depict associations.
We performed citation analysis on sources, authors, and documents, country, year, and author keyword co-occurrence analysis.The flow of the research approach used in this study is depicted in Figure 1.Research on surgical safety checklists has increased year by year, from 2017 to 2022.It has decreased in 2020; this was made possible due to the COVID-19 pandemic, which has had an impact on studies where services in hospitals focus on patient care, but increased again in 2021 and slightly decreased again in 2022.

Publication by Countries
. for surgery is still being carried out in America and Europe.We hope that in the future similar studies can be carried out in Asia and especially in Indonesia.

Publication by Subject
According to the research boundaries that have been selected, most research on the surgical safety checklist is carried out in the fields of Medicine (81%), nursing (15%), Pharmacology, toxicology, and pharmaceuticals (2%), Biochemistry, genetics, and Molecular Biology (1%), and Health Professions (1%).The Surgical Safety Checklist is used in only 15% of nursing research.This can yet be developed with additional detailed research on the surgical safety checklist.The relationship between research elements in the study of surgical safety checklists illustrates the strong relationship between checklists, procedures, and patient safety.Using a surgical safety checklist, doctors, anesthesiologists, nurses, and surgical staff must communicate and comply with the procedure during a surgical procedure.Given the importance of this Patient Safety Checklist, there is the term no SSC, no knife.If this has become a culture, then the use of a surgical checklist will become a safety culture in the hospital.
Based on network visualization, three research clusters on surgery safety checklists were identified: cluster 1 has 14 items, cluster 2 has 10 items, and cluster 3 has 9 items.Clinical audit, communication, education, personal health attitude, interpersonal communication, medical education, nurse, personal operating room, operating rooms, organization and management, patient care teams, safety, safety culture, safety management, surgeon, surgical safety checklist, teamwork Describe SSC activities in the operating room as a medium of interpersonal communication that carries out operational activities that require organization, which has an impact on creating a safety culture.Something that becomes a culture will always be carried out because the whole person will feel that something is missing if this is not done.
Patient safety, procedure, checklist, healthcare personnel, practice guideline, quality improvement, statistics and numerical data, drug safety, retrospective study, standards, hospitals, medical errors, and medical errors are interconnected to demonstrate that patient safety procedures are standards that must be carried out continuously, which can prevent medical errors during surgical procedures performed in the operating room.This is not a one-time activity but rather one that will continue as long as the operation is being performed.

Most Citation of Surgical Safety Checklist
Here, most citations of publication of surgical safety checklist; The number of citations to research on surgical safety checklists illustrates that many people want to learn and develop SSC in surgical services.The interest in referencing SSC research is very great; among the ten largest data sets on SSC citations, the ten lowest orders still receive 41 citations.Overlay visualization of the surgical safety checklist that has been drawn provides valuable insights about the relationship between elements related to safety in operations.A surgical safety checklist is a tool used to ensure important steps are carried out systematically and consistently during surgical procedures to minimize the risk of errors and improve patient safety.

Overlay Visualization
In the context of overlay visualization using the VOSviewer application, elements that can be represented by nodes in the network may include components from the surgical safety checklist, including the sign-in, time-out, and sign-out processes.
Patient Safety is connected to the green line with elements of checklist, procedure, surgery, WHO, clinical outcome, surgical mortality, length of stay, hospital, operating room, safety procedure, surgeon, teamwork, and clinical audit.
The purple line connects standards with elements of surgical procedures: operative, medical error, organization and management, and the patient care team.This illustrates that SSC is a standard procedure carried out by the operating team on an ongoing basis that requires good management and organization.
The yellow connecting line illustrates the relationship between the technique of implementing SSC and the elements of surgical technique, Anaesthesia, drug safety, the perioperative period, perioperative care, interpersonal communication, and adverse events.

Density Visualization
Figure 9. Density Visualization Density visualization of the surgical safety checklist helps us understand the extent to which this checklist is applied consistently and thoroughly in clinical practice, including patient safety, the checklist, procedures, and surgeries.This Information can be used to identify areas for improvement, develop more effective interventions, and improve patient safety during surgical procedures.

Discussion
Based on the 292 paper surgical safety checklist, although the surgical safety checklist is a procedure that must be done during an operating procedure, there is an urgent need to raise awareness about the safety checklist, and one method to do so is through demonstration papers at international conferences (Malhotra et al. 2017).
A surgical safety checklist is a protocol that must be followed at all times during an operation to ensure the patient's surgical safety.There is a Team timeout, which has proven useful in improving patient safety with minimal effort.Despite various preoperative safeguards, errors can occur and can be detected by performing a team timeout (Weingessel et al. 2017).
This research is inline with the research by Kisacik and Cigerci (2019) that surgical safety checklist enhancements focusing on the formation of a culture of patient safety and team collaboration in operating rooms are essential in order to use surgical safety checklist on a regular and proper basis (Kisacik and Cigerci 2019).Any research conducted by Gillespi at al (2018) that's The advantage of having a surgical checklist is that it has the ability to improve team communication and establish a team culture in which safety is prioritized (Gillespie et al. 2018).
The result of Gong research found that Surgeons' awareness was lower than that of operating room nurses, especially in the Time-Out section.The majority of participants stated that operating room nurses had the highest level of protocol adherence, while surgeons had the lowest.Positive elements for effective adoption include active leadership by experienced operating room nurses, good training for surgical team members, and the simplicity of the checklist.Although the Surgical Safety Checklist has widespread acceptability and acceptable self-reported awareness, it is not always possible to adequately implement it.Our findings imply that implementation difficulties can be overcome with experienced and competent leadership.With positive perception and commitment, the Surgical Safety Checklist is simple to apply and can significantly enhance patient safety (Gong et al. 2021).
Tully at al find that The ideal sign-out time was determined to be shortly following ultimate wound closure and before to unwrapping the patient (Tully et al. 2021) In Scotland, perioperative mortality has decreased since the checklist was implemented as part of a larger national safety policy.There were 12 667 926 hospital admissions, with 6 839 736 requiring surgery.In the surgical cohort, the inpatient mortality rate in 2000 was 076 (95 percent c.i. 068 to 084%), while it was 046 (042 to 050) in 2014.The checklist was linked to a 366 (95 percent confidence interval -552 to -179) percent relative reduction in mortality (P < 001).Before implementation, mortality rates were decreasing by 003 (95 percent c.i. -0017 to +0012) percent per year; annual decreases of 0069 (-0092 to -0046) percent were seen during, and 0019 (-038 to +0001) percent after differences were used to estimate the balance of demographics over time, after which interrupted time-series (segmented regression) analyses were performed (Ramsay et al. 2019).
Researched by Barbanti et al found that The SSC appears to be a useful technique for reducing problems in spine surgery.To further reduce the occurrence of problems, we advise extending the usage of the checklist system to the preoperative and postoperative periods (Barbanti-Brodano et al. 2020).
The SSC implementation quality was determined to be unsatisfactory, with significant room for improvement.Compliance with all criteria on the checklist, as well as active engagement by all team members, are critical for the checklist's successful implementation (Ambulkar et al. 2018).
A qualitative study by Harris et al found that A wide range of risk elements were discovered for a patient safety checklist.Creating a surgical safety checklist based on these risk factors may help to avoid complications and unintended errors (Harris et al. 2020).

CONCLUSIONS
A study discovered low levels of compliance with the WHO SSC.There was a statistically significant link between this level of compliance and the occurrence of discomfort and loss of consciousness postoperatively.(Igaga et al. 2018).
In another study, the process of handing over pre-operative patients was completed rather successfully, but there were still flaws to be addressed.Nurses regarded the use of the handover checklist for preparing pre-operative patients positively.(Nhut, Xuan, and Einhellig 2020).
Although SSC implementation remains inadequate in this comprehensive analysis, the surgical safety checklist implementation reduced patient mortality in surgery (Ramsay et al. 2019), reduced the occurrence and problem in surgery (Barbanti-Brodano et al. 2020), avoid complications and unintended errors (Harris et al. 2020), despite several preoperative protections, errors can occur and can be caught by performing a team timeout.(Weingessel et al. 2017) and become a simple technique that can considerably improve patient safety.
Even though it was launched by WHO more than 10 years ago, the SSC will never become an outdated procedure.It will be used today and will continue to be used in the future, just like patient safety impact, which we must prioritize as part of patient health services in hospitals, it will be always part of hospital safety culture.

Figure 1 .
Figure 1.Flow of Research Methode

Figure 3 .
Figure 3. Publication by Countries

Figure 4 .
Figure 4. Publication by Subject

Figure 5 .
Figure 5. Publication by University

Figure
Figure 8. Overlay Visualization According to the limitations mentioned about surgical safety checklists, the three major studies on surgical safety checklists were conducted by King's College London, Harvard Medical School, and Ariadne Labs; there were eighteen, sixteen, and fifteen studies, respectively.Further, there were fourteen studies conducted by Brigham and Women's Hospital, thirteen studies by Harvard, T.H. Chan School of Public Health, and ten studies by Heukeland Universitetssjukehus and Massachusetts General Hospital.And in eighth place, there are nine studies conducted by Universitet i Bergen.
Figure 6.Publication by publisher Research on the surgical safety checklist in the period 2017-2022, according to predetermined limits, included at most seventeen Sevdalis.N, eleven studies carried out by Weiser, T.G., and nine studies carried out by researchers Softeland, E.,E. and Haugen,A.S. Eight studies carried out by White, M.C., and seven studies carried out by Leather, AJM The studies carried out by Haynes, A.B., Harthug, S., and Gillespie, B.M. Five studies were carried out by Alidine, S. From 2017 through 2022, research on surgical safety checklists has increased year by year.

Table 2 .
Most Citation of Surgical Safety Checklist