Surgical safety checklists: do they improve outcomes?

The concept of using a checklist in surgical and anaesthetic practice was energized by publication of the WHO Surgical Safety Checklist in 2008. It was believed that by routinely checking common safety issues, and by better team communication and dynamics, perioperative morbidity and mortality could be improved. The magnitude of improvement demonstrated by the WHO pilot studies was surprising. These initial results have been confirmed by further detailed work demonstrating that surgical checklists, when properly implemented, can make a substantial difference to patient safety. However, introducing surgical checklists is not as straightforward as it seems, and requires leadership, flexibility, and teamwork in a different way to that which is currently practiced. Future work should be aimed at ensuring effective implementation of the WHO Surgical Safety Checklist, which will benefit our patients on a global scale.

[1]  Peter J Pronovost,et al.  Eliminating catheter-related bloodstream infections in the intensive care unit* , 2004, Critical care medicine.

[2]  R. Reznick,et al.  Evaluation of a preoperative team briefing: a new communication routine results in improved clinical practice , 2011, Quality and Safety in Health Care.

[3]  P. McCulloch,et al.  The effects of aviation-style non-technical skills training on technical performance and outcome in the operating theatre , 2009, Quality & Safety in Health Care.

[4]  Gerald Doppelt,et al.  The moral limits of Feinberg's liberalism , 1993 .

[5]  J. Lavoie,et al.  Handover after pediatric heart surgery: A simple tool improves information exchange* , 2011, Pediatric critical care medicine : a journal of the Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies.

[6]  Peter J Pronovost,et al.  Sustaining reductions in catheter related bloodstream infections in Michigan intensive care units: observational study , 2010, BMJ : British Medical Journal.

[7]  Stuart R. Lipsitz,et al.  Effect of A 19-Item Surgical Safety Checklist During Urgent Operations in A Global Patient Population , 2010, Annals of surgery.

[8]  P. Pronovost,et al.  Clinical review: Checklists - translating evidence into practice , 2009, Critical care.

[9]  R. Gibberd,et al.  Adverse events in surgical patients in Australia. , 2002, International journal for quality in health care : journal of the International Society for Quality in Health Care.

[10]  W. Berry,et al.  Perspectives in quality: designing the WHO Surgical Safety Checklist. , 2010, International journal for quality in health care : journal of the International Society for Quality in Health Care.

[11]  S. Skevington,et al.  ‘Skating on thin ice?’ Consultant surgeon's contemporary experience of adverse surgical events , 2012, Psychology, health & medicine.

[12]  Stuart R Lipsitz,et al.  Global operating theatre distribution and pulse oximetry supply: an estimation from reported data , 2010, The Lancet.

[13]  T. Ikonen,et al.  A pilot study of the implementation of WHO Surgical Checklist in Finland: improvements in activities and communication , 2011, Acta anaesthesiologica Scandinavica.

[14]  The implementation of a perioperative checklist increases patients' perioperative safety and staff satisfaction , 2012, Acta anaesthesiologica Scandinavica.

[15]  P. Davis,et al.  Adverse events in New Zealand public hospitals I: occurrence and impact. , 2002, The New Zealand medical journal.

[16]  C. Hartnick,et al.  Interdisciplinary Development and Implementation of Communication Checklist for Postoperative Management of Pediatric Airway Patients , 2012, Otolaryngology--head and neck surgery : official journal of American Academy of Otolaryngology-Head and Neck Surgery.

[17]  L. Lidgren,et al.  Timing of preoperative antibiotics for knee arthroplasties: Improving the routines in Sweden , 2011, Patient safety in surgery.

[18]  R. Reznick,et al.  Evaluation of a preoperative checklist and team briefing among surgeons, nurses, and anesthesiologists to reduce failures in communication. , 2008, Archives of surgery.

[19]  A. McEwan,et al.  Patient handover from surgery to intensive care: using Formula 1 pit‐stop and aviation models to improve safety and quality , 2007, Paediatric anaesthesia.

[20]  E. D. de Vries,et al.  Effect of a comprehensive surgical safety system on patient outcomes. , 2010, The New England journal of medicine.

[21]  L. Kohn,et al.  To Err Is Human : Building a Safer Health System , 2007 .

[22]  J. Birkmeyer.  Strategies for improving surgical quality--checklists and beyond. , 2010, The New England journal of medicine.

[23]  E. McGrady,et al.  The introduction of a surgical safety checklist in a tertiary referral obstetric centre , 2011, Quality and Safety in Health Care.

[24]  P. Pronovost,et al.  An intervention to decrease catheter-related bloodstream infections in the ICU. , 2006, The New England journal of medicine.

[25]  ra Laura Estefanía Aguilar-Sierra.  A safe surgery saves lives , 2010 .

[26]  W. Berry,et al.  An estimation of the global volume of surgery: a modelling strategy based on available data , 2008, The Lancet.

[27]  Nick Sevdalis,et al.  Evaluation of Postoperative Handover Using a Tool to Assess Information Transfer and Teamwork , 2011, Annals of surgery.

[28]  J. Reason.  Human error: models and management , 2000, BMJ : British Medical Journal.

[29]  R. Flin,et al.  Training in non-technical skills to improve patient safety , 2009 .

[30]  A. Edmondson.  Speaking Up in the Operating Room: How Team Leaders Promote Learning in Interdisciplinary Action Teams , 2003 .

[31]  T H Kappen,et al.  Effects of the Introduction of the WHO “Surgical Safety Checklist” on In-Hospital Mortality: A Cohort Study , 2012, Annals of surgery.

[32]  B. Pedersen,et al.  [Incidence of adverse events in hospitals. A retrospective study of medical records]. , 2001, Ugeskrift for laeger.

[33]  W. Berry,et al.  Changes in safety attitude and relationship to decreased postoperative morbidity and mortality following implementation of a checklist-based surgical safety intervention , 2011, Quality and Safety in Health Care.

[34]  John E. Ziewacz,et al.  Crisis checklists for the operating room: development and pilot testing. , 2011, Journal of the American College of Surgeons.

[35]  T. Brennan,et al.  Costs of medical injuries in Utah and Colorado. , 1999, Inquiry : a journal of medical care organization, provision and financing.

[36]  P. Barach,et al.  Five System Barriers to Achieving Ultrasafe Health Care , 2005, Annals of Internal Medicine.

[37]  Lorelei Lingard,et al.  Team Communications in the Operating Room: Talk Patterns, Sites of Tension, and Implications for Novices , 2002, Academic medicine : journal of the Association of American Medical Colleges.

[38]  Isabeau A Walker,et al.  Anaesthesia in developing countries—a risk for patients , 2008, The Lancet.

[39]  P. McCulloch,et al.  The influence of non-technical performance on technical outcome in laparoscopic cholecystectomy , 2007, Surgical Endoscopy.

[40]  Sara J Singer,et al.  Effective surgical safety checklist implementation. , 2011, Journal of the American College of Surgeons.

[41]  James T. Reason,et al.  Behavioural markers of surgical excellence , 2003 .

[42]  A. Gawande,et al.  Accidental deaths, saved lives, and improved quality. , 2005, The New England journal of medicine.

[43]  T. Brennan,et al.  INCIDENCE OF ADVERSE EVENTS AND NEGLIGENCE IN HOSPITALIZED PATIENTS , 2008 .

[44]  J. Reason,et al.  Human factors and cardiac surgery: a multicenter study. , 2000, The Journal of thoracic and cardiovascular surgery.

[45]  Don K Nakayama,et al.  Quality improvement and patient care checklists in intrahospital transfers involving pediatric surgery patients. , 2012, Journal of pediatric surgery.

[46]  W B Runciman,et al.  A comparison of iatrogenic injury studies in Australia and the USA. I: Context, methods, casemix, population, patient and hospital characteristics. , 2000, International journal for quality in health care : journal of the International Society for Quality in Health Care.

[47]  S. Sheps,et al.  The Canadian Adverse Events Study: the incidence of adverse events among hospital patients in Canada , 2004, Canadian Medical Association Journal.

[48]  Alan F. Merry,et al.  International Standards for a Safe Practice of Anesthesia 2010 , 2010, Canadian journal of anaesthesia = Journal canadien d'anesthesie.

[49]  Ruth Thorlby,et al.  High Quality Care For All , 2008 .

[50]  K. Catchpole,et al.  Improving patient safety by identifying latent failures in successful operations. , 2007, Surgery.

[51]  E. Ackermann.  The Quality in Australian Health Care Study. , 1996, The Medical journal of Australia.

[52]  W. Berry,et al.  A Surgical Safety Checklist to Reduce Morbidity and Mortality in a Global Population , 2009, The New England journal of medicine.

[53]  H. Adams.  Global oximetry: an international anaesthesia quality improvement project , 2010, Anaesthesia.

[54]  R. Berrisford,et al.  Surgical time out checklist with debriefing and multidisciplinary feedback improves venous thromboembolism prophylaxis in thoracic surgery: a prospective audit. , 2012, European journal of cardio-thoracic surgery : official journal of the European Association for Cardio-thoracic Surgery.

[55]  A. Gawande,et al.  The incidence and nature of surgical adverse events in Colorado and Utah in 1992. , 1999, Surgery.

[56]  R. Reznick,et al.  Communication failures in the operating room: an observational classification of recurrent types and effects , 2004, Quality and Safety in Health Care.

[57]  Peter J Pronovost,et al.  Reality check for checklists , 2009, The Lancet.

[58]  James P Bagian,et al.  Association between implementation of a medical team training program and surgical morbidity. , 2011, Archives of surgery.

[59]  Trevor A Sheldon,et al.  Sensitivity of routine system for reporting patient safety incidents in an NHS hospital: retrospective patient case note review , 2006, BMJ : British Medical Journal.

[60]  R. Helmreich.  On error management: lessons from aviation , 2000, BMJ : British Medical Journal.

[61]  J. Neily,et al.  Association between implementation of a medical team training program and surgical mortality. , 2010, JAMA.

[62]  L. Moxey,et al.  Strengthening handover communication in pediatric cardiac intensive care , 2012, Paediatric anaesthesia.

[63]  C. Vincent,et al.  Adverse events in British hospitals: preliminary retrospective record review , 2001, BMJ : British Medical Journal.

[64]  P. Truran,et al.  Does using the WHO surgical checklist improve compliance to venous thromboembolism prophylaxis guidelines? , 2011, The surgeon : journal of the Royal Colleges of Surgeons of Edinburgh and Ireland.

[65]  K Moorthy,et al.  Practical challenges of introducing WHO surgical checklist: UK pilot experience , 2010, BMJ : British Medical Journal.

[66]  E. Rogers.  Diffusion of Innovations , 1962 .

[67]  A. Bleakley,et al.  Pre-surgery briefings and safety climate in the operating theatre , 2011, Quality and Safety in Health Care.

[68]  T. Brennan,et al.  Incidence and types of adverse events and negligent care in Utah and Colorado. , 2000, Medical care.

[69]  J. Kane,et al.  Standardized multidisciplinary protocol improves handover of cardiac surgery patients to the intensive care unit* , 2011, Pediatric critical care medicine : a journal of the Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies.