Simon Hendel: The big tick

A LOT has been written about the role of checklists in improving the safety of surgery.

The WHO, through its Safe Surgery Saves Lives initiative, led the development of the WHO Surgical Safety Checklist (SSC).

In 2007–2008, the SSC was piloted in eight hospitals in both high- and low-income countries, with the results published in the New England Journal of Medicine in 2009.

I’m simplifying, but in essence the study showed that after the implementation of the SSC there was a reduction in the surgical death and complication rate by more than one-third, with a halving of the surgical death rate alone.

Striking results indeed.

The WHO estimates about 234 million people are operated on each year and, by current estimates just over a million of these people — many in low-income countries — will die from complications. Extrapolating from the NEJM study, 500 000 people who would otherwise die could be saved if the surgical safety checklist was used as intended.

Half a million people every year.

So why are there opponents to the widespread and mandated use of the SSC? Some see the compulsory use of checklists as “cookbook medicine” while others see it as an unnecessary additional workload — another form to tick, in an already paperwork-heavy workplace.

Others see the surgical checklist as just another example of bureaucrats getting in the way of the main game of getting surgery done.

To an extent, I agree with some of these arguments. The burden of mandatory forms and signatures required for even the simplest of cases can be frustrating, and can make it difficult to separate the signal from the noise.

Still, others see the use of the checklist as simply ineffective at improving outcomes. A recent study, also published in the NEJM, detailed the experience of investigators in Ontario, Canada after the implementation of the SSC.

What did they determine? No difference.

Their already impressively low rates of postoperative complications and death were not further improved with the surgical safety checklist — at least not in a largely noticeable or significant way. They demonstrated the principle of diminishing returns and showed that the better you are to begin with, the harder it is to improve.

But what about the diploma-trained anaesthesia technical officer in rural Uganda, who is prompted to use a pulse oximeter or notices the oxygen cylinder is empty during their similarly prompted machine check?

Does it make a difference then? Should they read the NEJM paper and similarly dismiss the checklist? I think not.

Even in Ontario, for the one, or two, or maybe 10 people who avoided surgical site infection because their anaesthetist was prompted by the list to give antibiotics prior to skin incision — it made a difference to them, too.

Perhaps the checklist made a difference also for the junior nurse, who now knows the names of the people he works with and might feel more able to speak up if he doesn’t understand the plan or sees something dangerous about to happen.

Don’t throw the baby out with the bathwater. Checklists by themselves are just another piece of paper, but it’s not about the piece of paper.

It’s about the culture of a surgical team and its ability to work effectively all of the time and not just most of it. It’s about getting the simple things — like antibiotics and thromboprophylaxis and oxygen and each others’ names — right, every time.

Aviators are surprised that checklists like they use are not used in medicine. Early on in their history, they had their fair share of “oops-forgot-the-landing-gear” moments, and they have used checklists to adapt their culture to the increasingly complex demands of flying.

Until we come up with a better idea, checklists seem like a pretty good way for us to adapt our culture to the growing complexity of surgery.

Dr Simon Hendel is an anaesthetist and an intern at the Global Surgical Consortium.