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Checklists as tools for safety have demonstrated value in complex systems and thus have been mandatory in the aviation industry. Until recently, they were missing from medicine, save the anesthesia pre-induction checklist. Now, checklists are being adopted in hospitals, yet without standardization beyond the pre-procedure time out. The inherent complexities of surgical procedures, critical and emergency care strategies, and technology are magnified exponential when combined as a system for care. Such complexity allows the possibility for alignment of component failures that can result in catastrophic outcomes. Synchronizing all system components before “go” helps to reduce the opportunities for serious error.
As the number of surgical procedures worldwide approaches the quarter-billion mark, initiatives to improve outcome by reducing errors have multiplied. One such initiative is the World Health Organization (WHO) surgery checklist. Comprised of 19 items, the checklist improves communication among members of the surgical team and prevents errors of omission and commission.
As reported by Haynes and colleagues1, use of the WHO surgery checklist was associated with a substantial reduction in the rate of complications within 30 days of operation in a diverse group of nearly 4,000 patients undergoing surgical procedures. The mortality rate was cut in half from 1.5% to 0.8%, and the complication rate was reduced by over one third, from 11% to 7%. The spectrum of measured complications was broad and consistent with definitions from the American College of Surgeons National Surgical Quality Improvement Program and captured a broad spectrum: acute renal failure, transfusion of > 4 units of red blood cells within 3 days of surgery, cardiac arrest requiring cardiopulmonary resuscitation, coma lasting more than 24 hours, venous thromboembolism, myocardial infarction, unplanned intubation, post-operative ventilator use > 48 hours, stroke, acute wound failure, surgical site infection, the sepsis continuum, vascular graft failure, and unplanned reoperation. Six standard safety processes were measured as well and included
• Accurate preoperative airway evaluation
• Use of pulse oximetry at anesthesia initiation
• Sufficient vascular access, given anticipated blood loss
• Prophylactic antibiotic administration within one hour of incision
• Performance of a time out before incision to confirm patient name, operative site, and pending operation
• Completion of a sponge count at the end of the operation
The Surgical Care and Outcomes Assessment Program (SCOAP) in Washington State is disseminating a modified checklist (Figure) as best practice. The elements of the checklist are not “rocket science.” They constitute essentials for intra-team relationships. In executing the checklist, all members of the operative team (surgeons, nurses, and anesthesia providers) affirm a common understanding about what they are going to do and voice anticipation of potential problems. The checklist process begins with Step 1, the pre-operative briefing. Collectively, the team confirms patient identity, operative site, and intended operation. Then, anesthesia, nursing, and surgeon review sequentially issues in their respective domains. Step 2 reviews important quality and safety processes that have been previously defined as best practice. This step was not an original part of the WHO checklist, yet is readily incorporated in the checklist approach. Included are confirmation of the display of essential imaging, active warming, glucose control, beta-blockade, DVT prophylaxis, antibiotic prophylaxis, presence of vital equipment (e.g., cell-saver, specific instruments), and sharps injury prevention plan. Step 3, the debriefing, begins as the operation nears completion before incision closure and opens with the question, “Are the instrument, sponge, and needle counts correct?” The response is verbalized to the entire team and allow for immediate corrective action if incorrect. The members of the team then review the operation, reiterating the important activities that should have occurred, and verifying that the specimen has been appropriately handled with confirmation of patient identity on the specimen and special instructions for the pathologist. Opportunities for improvement are addressed with equipment and processes, and the key post-operative concerns are verbalized. The reasons that checklists improve outcome are likely multiple, but the common pathway is a reduction in variability. Changes in systems and surgical team behavior occur. Behavior in studies may be positively influenced by team members knowing that they are being observed, rather than by completion of the checklist in and of itself. Yet the question is, from where does the checklist drive accountability? Intra-team, rather than external observation, may play a larger role. It is important to remember that the checklist is a means to an end, not the end itself. Given its extremely low cost in time and resources, associated with clear improvement in outcomes, the checklist is a simple tool that has come of age in health care delivery. Citations: 1. Haynes, et. Al, A Surgical checklist to reduce Morbidity and Mortality in a Global Population. NEJM, January 29, 2009 p491-499. 2. http://www.scoap.org/checklist/index.html (includes a video interview of the process with Dr. E. Patchen Dellinger)
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