The surgical safety checklist has been mandated or strongly encouraged by several governments since Haynes et coauthors found it to reduce morbidity and mortality in a global population (N Engl J Med 2009;360:491-9). Recently Urbach et al, found conflicting results with the Introduction of surgical safety checklists in Ontario, Canada (N Engl J Med 2014;370:1029-38). What didn't work? Do we need to implement our checklist? Or do we need simply to change our practice and use the available checklists in the correct way?
Dear Sergio
These 02 articles my be useful for you:
1) Am Surg. 2011 Sep;77(9):1131-7.
The surgical safety checklist: lessons learned during implementation.
Calland JF1, Turrentine FE, Guerlain S, Bovbjerg V, Poole GR, Lebeau K, Peugh J, Adams RB.
Abstract
Procedural checklists may be useful for increasing the reliability of safety-critical processes because of their potential capacity to improve teamwork, situation awareness, and error catching. To test the hypothesized utility and adaptability of checklists to surgical teams, we performed a randomized controlled trial of procedural checklists to determine their capacity to increase the frequency of safety-critical behaviors during 47 laparoscopic cholecystectomies. Ten attending surgeons at an academic tertiary care center were randomized into two equal groups - half of these surgeons received basic team training and used a preprocedural checklist whereas the other half performed standard laparoscopic cholecystectomies. All procedures were videotaped and scored by trained reviewers for the presence of safety-critical behaviors. There were no differences detected in patient outcomes, case times, or technical proficiency between groups. Cases performed by surgeons in the intervention (checklist) group were significantly more likely to involve positive safety-related team behaviors such as case presentations, explicit discussions of roles and responsibilities, contingency planning, equipment checks, and postcase debriefings. Overall, situational awareness did not significantly differ between the intervention and control groups. Participants in the intervention (checklist) group consistently rated their cases as involving less satisfactory subjective levels of comfort, team efficiency, and communication compared with those performed by surgeons in the control group. Surgical procedural safety checklists have the capacity to increase the frequency of positive team behaviors in the operating room during laparoscopic surgery. Adapting to the use of a procedural checklist may be initially uncomfortable for participants
2) Ann Surg. 2013 Dec;258(6):856-71.
Do safety checklists improve teamwork and communication in the operating room? A systematic review.
Russ S1, Rout S, Sevdalis N, Moorthy K, Darzi A, Vincent C.
Abstract
OBJECTIVES:
The aim of this systematic review was to assess the impact of surgical safety checklists on the quality of teamwork and communication in the operating room (OR).
BACKGROUND:
Safety checklists have been shown to impact positively on patient morbidity and mortality following surgery, but it is unclear whether this clinical improvement is related to an improvement in OR teamwork and communication.
METHODS:
A systematic search strategy of MEDLINE, EMBASE, PsycINFO, Google Scholar, and the Cochrane Database for Systematic Reviews was undertaken to obtain relevant articles. After de-duplication and the addition of limits, 315 articles were screened for inclusion by 2 researchers and all articles meeting a set of prespecified inclusion criteria were retained. Information regarding the type of checklist, study design, assessment tools used, outcomes, and study limitations was extracted.
RESULTS:
Twenty articles formed the basis of this systematic review. All articles described an empirical study relating to a case-specific safety checklist for surgery as the primary intervention, with some measure of change/improvement in teamwork and/or communication relating to its use. The methods for assessing teamwork and communication varied greatly, including surveys, observations, interviews, and 360° assessments. The evidence suggests that safety checklists improve the perceived quality of OR teamwork and communication and reduce observable errors relating to poor team skills. This is likely to function through establishing an open platform for communication at the start of a procedure: encouraging the sharing of critical case-related information, promoting team coordination and decision making, flagging knowledge gaps, and enhancing team cohesion. However, the evidence would also suggest that when used suboptimally or when individuals have not bought in to the process, checklists may conversely have a negative impact on the function of the team.
CONCLUSIONS:
Safety checklists are beneficial for OR teamwork and communication and this may be one mechanism through which patient outcomes are improved. Future research should aim to further elucidate the relationship between how safety checklists are used and team skills in the OR using more consistent methodological approaches and utilizing validated measures of teamwork such that best practice guidelines can
There is a very nice TED talk on the topic featuring Atul Gawande, who was the principal in the original WHO study into pre-operative check-lists. It is quite interesting. As you probably know, they reported a 30% improvement of outcomes attributable to checklist.
That being said, the checklist is merely an additional safety net in a high-risk environment, in which multiple safe-guards should be in effect. The checklist cannot be expected to in of itself impact infection rates or improve the technical performance of the operator. It is designed to prevent the so-called 'never' events, such as retained instruments and swabs, and wrong-side surgery. It is unclear from the abstract whether the authors of the Canadian study looked into that.
Besides, it is one retrospective study, which does not shift the balance of extant evidence appreciably.
http://www.nrls.npsa.nhs.uk/EasySiteWeb/getresource.axd?AssetID=60217&type=full&servicetype=Attachment
I think that ther are some misleading issues. For istance, I consider that doing an ultimate checklist after patients sleeping is redundant. After anesthesia administration we must be sure that we are operating the correct patient for the correct disease, performing the correct and safe procedures. I cannot think that a pilot does repeat the fligt checklist after the take off. At that time what you had to do, you did it.
When I started to become a surgeon I had to learn some lessons. The first and most important lesson was to know the details of the disease of the patient I started to operate upon. I had to learn how to diagnose his/her disease and then the operation and postoperative care, too. The patients were from the ward I was responsible. The consultants knew all the histories,too. But now, these times are gone! We work in surgery like in industry and it was a very astonishing fact to listen to the stories told during "team time-out"! Sometimes I thought/think this is another patient! In this way with the WHO-safety list you should be forced to know your patients better! But I do not believe in improving quality of surgery or treatment just by introducing the safety list.
I believe surgical safety checklists improve patient outcomes and safety and their implementation is neccessary, but not adequate. This is one more armament for the physician, surgeon in this case, to improve the quality of care. However, we should know and check our patient thoroughly and not rely on a filled check list. It may turn out to be a "PSEUDO-ASSURANCE".
The surgical safety checklist only serves as a checklist to make one wonder about what he's doing. If not used that way it may even be more dangerous to use them.
Dear Sergio
Great Question... Surgical Checklist alone can not improve patient outcome, but the PROCESS & COMPLIANCE shall... An wonderful checklist without process and compliance can not help out...
Recently read an article of leaving surgical materials inside the body and causing an excessive pain and then needing for a re-surgery...
I have observed and witnessed surgeons are under tremendous pressure in surgical room and anaesthetist too in ensuring surgery is completed fast...
Kindest Regards
Ramanan
Dear Ramanan,
i couldn't agree more. Compliance is the main word. Taking the time to stop an check without the pressure of having to move on, a real time out, is essential in this process.
Than it will lead to a greater safety.
Dear researchers,
I'm pleased for the great number of your replies and for the interest you showed for this important issue. At this regard I'm sure you will enjoy reading this new article by Gillespie et al published in the last issue of Anesthesiology:
Brigid M. Gillespie, et al. Effect of Using a Safety Checklist on Patient Complications after Surgery. A Systematic Review and Meta-analysis. Anesthesiology 2014; 120:1380-9.
These authors conclude their review and Meta-analysis suggesting that notwithstanding the lack of randomized controlled trials, checklists are associated with a reduction in overall complications in surgical patients.
In few words, it will be very difficult to demonstrate the superiority of checklist based surgery towards standard practice because no RCT have been published and perhaps no one will be performed since that checklists have become synonymous of best practice and nowadays legal implications prevent clinicians to operate without them. Thus, only prospective studies with historical control are available. After all, I will be afraid to fly if I knew that an RCT is ongoing comparing checklist flights versus checklist free flights.
Thus, it is very hard to speculate that checklists don't improve our practice. It's hard to believe that the attitude to methodically control that it's all right before starting the operation will not help avoid some stupid and preventable errors. Moreover it's hard to think that checklists, don't improve communication between the members of the team and the quality of teamwork. So, I think that we should use checklists and to improve the culture of safety in the operating room. There is no doubt about it.
I think we will now discuss about methods. How checklists should be to best fit to our daily practice. How many and what parameters have to be checked before the operation starts? Are long and boring multi parameter checklist to be discouraged in favor of short lists of few but pivotal issues as the original WHO list was?
The surgical check list is the last check in the process. The most important check is the first check - and it isn't on the check list. It starts from the moment the case is scheduled. From step one the case begins to build its own profile. If it isn't correct when scheduled, the case immediately develops potential risk and the magnitude of such risk is unknown. The Joint Commission Center for Transforming Healthcare shares the Reducing the Risk of Wrong Site Surgery Targeted Solution Tool provided by them to accredited organizations who wish to study their defenses and identify their weakness that make them vulnerable to having a wrong site event. It's a Robust program incorporating tools and methods from Lean Six Sigma and change management methodologies.
No RCT's are needed. The reduced complication rate is large enough.
Many physicians and surgeons wrongly believe that EBM means RCT based evidence. This is wrong.
Suppose you find a new way of treating a disease a disease which is uniformly fatal. You treat 3 patients, and 2 of them recover.
This is a very strong evidence that the new treatment is successful. Much stronger evidence than an RCT which shows a decrease in mortality from say 7% to 4% with a p value
Safety checklists, WHO checklists - whatever you call them are only as good or as bad as you use them.
In my personal experience over more than 40 years the best preventative measure for avoiding mistakes was the personal contact with the patient before being wheeled into the operating theatre.
The best conditions are always to know the patient personally and have his problems in mind.
Recollecting the last decades and the media reports about mishaps, they were all a result of a surgeon walking into a theatre, not knowing the patient, not knowing his condition and following an operation list (in many instances not even compiled by a person with any medical knowledge).
In my personal experience these issues are always related to a disconnect of planning operations and the actual operting surgeon. I personally never walk into an operating theatre to operate on a patient I had not greeted in the preop holding bay, unless we are dealing with a serious emergency.
As a matter of principle I will not have the patient anaesthetised before I have spoken to him and having read the documents. This would be the truthful way for avoiding "wrong side", "wrong patient", etc. This appears to be hard to understand for doctors in London, NZ or Australia. The culture of waiting lists and "open lists" in my opinion is the ground for mistakes to happen.
In all the discussions about WHO checklists I would really like to see a culture -or if you like add-on- of asking why the patient is in theatre? The reason I am writing this is this: I am working in a Rural Hospital. I do have locums coming to this place and performing for instance endoscopies and colonoscopies. Unfortunately they never seem to read my inital referral letters. Accordingly they do not perform the endoscopies with the biopsies I had in mind when I referred the patient.
In other words: The WHO guidelines lack the connection to the patient. I have seen nonmedical staff -however employed in the environement of a theatre- manipulate the patient details to fit the wrong documentation file.
Maybe some day we will be able to come back to physician led medicine. Dump the administrators. According to the orignal sense of the term, they should adminster us! At the moment things seem to be upside down. Not good for our patients.
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