Associate Professor of Surgical Oncology, Department of Clinical Sciences, University of Florida, Gainesville, FL, USA
The use of surgical safety checklists saves lives and decreases complications. A common misconception of surgical checklists is that it takes more time.
Checklists are easy to implement and can quickly improve workflow and decrease stress.
Checklists are routinely used in the aviation industry to ensure safety and to remove human error. Failure to use a checklist by a pilot is considered a violation of flight protocol and a flight error. In the developed world, nearly half of all harmful events that affect human patients are related to surgical care, suggesting that improving safety with tools such as checklists has the potential to have a major impact on patient safety. Surgical checklists are becoming more common in human surgery with the aim of reducing surgical complication rate. The most notable recent publication to this end was published in The New England Journal of Medicine in 2009. Using a standard surgical checklist that involved anesthesia, OR personnel, ICU personnel and the surgical team, a system evolved that significantly reduced the global surgical complication rate in eight hospitals worldwide. The mortality rate declined from 1.5% to 0.8% with the use of the checklist and the inpatient complication rate decreased from 11.0% to 7.0% (N Engl J Med 2009).
The checklist creates three stop points that allow for communication between the surgical team members: prior to anesthesia, prior to the skin incision and prior to recovery. The first step is called sign in. Before induction of anesthesia, members of the team confirm the patient identity, surgical site, and risk of blood loss. Other items on the checklist that are more applicable to human patients are that the pulse oximeter is on and working, any known allergies are discussed and the risk of aspiration is assessed. The second step of the process is a time out just prior to making the incision. At this step, the entire team (including visitors and observers in the OR) are introduced, including their role, the patient identity, site and procedure are confirmed, the surgeon reviews critical and unexpected steps, the anesthesiologist review concerns and the nursing staff review equipment concerns. Confirmation of antibiotic administration and that the relevant imaging is displayed is also performed at this step. At the completion of the procedure, a third step, called time out, is performed. The procedure is recorded, needle, sponge and instrument count is complete, specimens are labeled, equipment issues are addressed and other concerns or necessary procedures prior to recovery are reviewed aloud.
Although the items on the checklist are all tasks and reminders that trained staff know must be done, the checklist serves to decrease complication rate by ensuring that nothing is missed. It also results in improved communication between team members and a culture shift that reinforces the significance of communication and working together to provide the best possible patient outcome.
There are some challenges to implementing a surgical checklist in your practice. It is important to remember that the checklist must be user friendly. It is tempting to add a lot of information to the checklist to make it an all-encompassing checklist for the patient's entire stay. It is important to resist this temptation and focus on the critical information to ensure patient safety. For example, confirming the patient identity, procedure and surgical site are critical. Remembering to trim the patient's toenails is not critical and should not be on your surgical checklist. The checklist can and should be modified to suit your own practice, but it must be quick and should only take 30–60 seconds to complete. The items on the checklist should be information that is communicated between the surgeon, anesthetist and OR nurses regularly. The goal of the checklist is to ensure that this information is communicated efficiently and that important items on the checklist are not forgotten due to human error or the assumption that someone else is responsible. A common example of this is the administration of perioperative antibiotics. Because it is the surgeon's responsibility to order the antibiotics, but the administration often is the responsibility of the anesthesia or OR team, this commonly falls between the cracks and antibiotics are not administered until after surgery starts. The appropriate use of timely prophylactic antibiotics is an extremely important component of preventing surgical site infections, but the importance of the timing is often overlooked. Antibiotics for prophylaxis should be administered 20–30 minutes prior to surgery for maximal efficacy.
The checklist must be simple and widely applicable to different types of surgical procedures. Resistance to implementation of a checklist is common, especially from surgeons. Some surgeons will feel that they already do a good job or that the suggestion that the side/site of surgery needs to be confirmed, or that an instrument count or sponge count is a good idea is insulting to them. The reality is that we are all human and mistakes are made, the wrong patient or site having surgery is an incredibly stressful event for the surgery team to undergo and, even if it is extremely rare, it is best avoided. Leaving a surgical sponge in a cavity can have devastating effect on the patient. When trying to implement a checklist in your practice, start small and work with the surgeons that are interested in participating. Sometimes this is what it will take to develop buy-in from the other surgeons and team members.
Below are the WHO checklist and the checklist developed by Dr. Boston. They can be modified to suit your own practice.
1. Haynes AB, Weiser TG, Berry WR, et al. A surgical safety checklist to reduce morbidity and mortality in a global population. N Engl J Med. 2009;360:491–499.
2. World Health Organization. Patient safety: tools & resources. www.who.int/patientsafety/safesurgery/tools_resources/en/index.html.
3. Gawunde A. The checklist manifesto: how to get things right.