A CHECKLIST that includes nearly 100 items has been advocated as a way to substantially reduce the number of adverse events for patients undergoing surgery.

A study from the Netherlands, published in the New England Journal of Medicine (NEJM), found that a substantial improvement in outcomes could be achieved for patients through use of a checklist that targeted the whole surgical pathway from admission to discharge.(1)

Australian hospitals have introduced the World Health Organization (WHO) Surgical Safety Checklist in operating theatres, in an initiative led by the Royal Australasian College of Surgeons, which involves checks from before the induction of anaesthesia to before the surgeon leaves the theatre.(2)

However, the Dutch study involved the implementation of the Surgical Patient Safety System (SURPASS), a multidisciplinary checklist.(3)

The results showed that after implementation of SURPASS the total number of complications was reduced from 27.3 per 100 patients to 16.3 — an absolute reduction of 10.6 complications.

The proportion of patients with one or more complications was 15.4% before the checklist was implemented, and 10.6% after.

In-hospital mortality was reduced from 1.5% to 0.8% and patients with temporary disability or who required a second surgical operation to resolve a complication also decreased significantly, from 2.7% to 1.1%.

These results were achieved despite the study being conducted in teaching and academic hospitals which already had high baseline standards of care.

Outcomes in hospitals used as controls did not change during the 3-month study period.

The study authors said the checklist incorporated all existing protocols and checks used at the hospitals, minimised information loss as patients moved through the system and promoted interdisciplinary communication.

“In all participating hospitals, many processes were optimised, including digital registration of blood-type cross-matching (incorporation into electronic records), standardisation of protocols, and standardisation of the timing of antibiotic prophylaxis,” the authors said.

Dr Michael Smith, medical director of the Australian Commission on Safety and Quality in Health Care, said the benefits of using the SURPASS checklist were believed to come as much from the improvements in communication between doctors, nurses and other members of the surgical team as from the specific contents of the checklist itself.

“What is important about this work is that it provides further supportive evidence that significant patient safety benefits can be achieved by the use of checklists in surgery,” Dr Smith said.

“It is too early to tell whether there is any greater benefit to be gained from the use of a much larger and more complex checklist than from use of the WHO Surgical Safety Checklist and ongoing work will be needed to answer that question.”

An editorial in the NEJM said the study should quiet the sceptics of checklists in hospitals.(4)

It said checklists could avert tens of thousands of surgical deaths and hundreds of thousands of serious complications every year.

“Although some questions remain, surgical checklists should be considered a priority for providers, payers, and policymakers,” the editorial said.

Dr Smith said the risk of “alert fatigue” raised in the editorial would need further investigation as experience with the use of checklists grows.

1. N Engl J Med 2010; 363:1928-1937.
2. Med J Aust 2010; 192: 631-632.
3. Qual Saf Health Care 2009;18:121-126.
4. N Engl J Med 2010; 363:1963-1965.


Posted 22 November 2010

4 thoughts on “Surgical checklists get a big tick

  1. Richard M says:

    A Surgical Time Out check list is an excellent device but it really should be performed BEFORE the patient is anaesthetised!!
    The “nurse protocols” (where would we be without those to whip us?) are usually applied after induction and are astonishingly resistant to change. However, I believe the College of Surgeons have wisely adopted a preinduction ruling. Hooray, where would we be without decent medical minds?
    The WHO checklist does rather go overboard though… Do I really care, or need to know, who the damn floor sweeper is as long as their mop is germ free, clean and working?

  2. Hugh Dillon says:

    John Lancaster is wrong to say that the aviation industry has abandoned checklists. You could not fly an aircraft without them. He and “anon” would throw the baby out with the bathwater. SIMPLE checklists that ease cognitive overload are good things. COMPLEX checklists are self-defeating. If the studies demonstrate that, in their place and used correctly, checklists work — as the WHO studies appear to show — checklists can save lives.

  3. anon says:

    I was given a six pages, hundreds-of-items checklist from a previous case while my registrar was intubating the next patient. Are we going to end up doing one case a day then 7 hours of paperwork? The brief time-out was sensible but the philosophy is now the more, the better. I offered to cancel the list so that we could continue the paperwork but the staff declined.

    And am I the only person who thinks it is ludicrous that a one-size-fits-all checklist can reduce complications by 50%? This just seems way out of proportion…

  4. John Lancaster says:

    Oh no – not another checklist – let’s hope it’s not in the gaudy ‘Emperor’s New Clothes’ variety of the WHO Safety List, only just forcefed on us. When will authorities wake up that checklists were abandoned by the aviation industry decades ago as they led to tedium-induced decerebration during a long list of pencil whipping. Checklists remove focus from the task in hand and lessen the degree of situational awareness that training, experience and vocation bring.
    Good for the hospital taking part in the study but any thoughts that would be translateable to a different country, cultural and demographic groups would be naive in the extreme.
    It is to my increasing despair and dismay that I see nurses distracted from patient care through the necessity of filling in ever longer checklists – often in triplicate!

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