Surgical safety checklists an important step in improving patient safety

Recently, I reviewed several impressive studies on surgical safety checklists which I’d like to comment on. These papers looked at its use for urgent cases, across a more extensive range of activities, and measured non-clinical outcomes; some addressed the effects of the World Health Organization (WHO) Surgical Safety Checklist and others the impact of the Surgical Patient Safety System (SURPASS). Although both checklists were developed to improve outcomes from surgery, WHO’s Surgical Safety Checklist focuses exclusively on the immediate pre-, intra-, and post-operative periods, while SURPASS addresses the entire surgical process of care, from the pre-operative period to discharge.

In a study published in the Annals of Surgery in May 2010, Effect of A 19-Item Surgical Safety Checklist During Urgent Operations in A Global Patient Population, Dr. Thomas G. Weiser specifically examined use of the WHO Surgical Safety Checklist for urgent surgical procedures. The results were not surprising—implementation of the checklist in these cases contributed to a greater than one third reduction in the rate of surgical complications as well as an almost two-thirds reduction in the mortality rate worldwide.

Similarly, Dr. Eefje N. De Vries published several papers on the impact in the Netherlands of the SURPASS checklist which includes the entire process of care (from the pre-operative period to discharge). His paper, Effect of a Comprehensive Surgical Safety System on Patient Outcomes, in the November 11^th 2010 issue of The New England Journal of Medicine showed a comparable decline in total complications and mortality to the WHO checklist. More recently, Dr. De Vries’ paper in the Annals of Surgery entitled, Prevention of Surgical Malpractice Claims by Use of a Surgical Safety Checklist looked at the potential effect of this more extensive checklist on malpractice claims rather than clinical outcomes. He concluded that nearly one third of contributing factors to surgical malpractice claims might have been intercepted by using the SURPASS checklist.

In many respects, checklists are instruments which facilitate communication amongst members of the clinical team. To get at this issue, Dr. Alex B. Haynes and his colleagues examined the association between postoperative outcomes following use of the WHO checklist and perceived safety culture. In Changes in safety attitude and relationship to decreased postoperative morbidity and mortality following implementation of a checklist-based surgical safety intervention, published in BMJ Quality & Safety, use of the WHO checklist was found to significantly improve postoperative outcomes. Most interestingly, however, these results were correlated with a subsequent increase in the improved perception of teamwork and safety climate of surgical teams. Haynes stated that, “nearly all [clinicians] responded that they would want the checklist used in their own care” and that the perception of the value of the checklist “suggests that a well-designed implementation programme can be successful in achieving clinician acceptance and use of the checklist.” His work supports the concept that these surgery checklists facilitate a collaborative practice model that changes the environment in which surgical teams practice.

Surgical safety checklists are tools to help avoid error and to facilitate communication amongst members of the clinical care team. Instituting a surgical safety checklist is a very important step toward improving surgical safety and team collaboration, but it is only one step and needs to be part of a more encompassing, strategic effort toward improving patient safety and clinical practice made on the organizational level. At APS, we believe that clinical practice is best performed as a coordinated effort involving all members of the care team. Our courses augment a collaborative practice model by providing common education to everyone on the clinical care team. Physicians, nurses, surgical technicians and others can learn about those critical elements of common procedures like a herniorrhaphy, colectomy or cholecystectomy that most often lead to errors, adverse outcomes and law suits. For example, anatomical variations of the cystic duct are illustrated along with simple techniques to identify key structures. This type of education not only ensures that all team members have the same base level of understanding and share a common language to facilitate communication, but also empowers each to individually and effectively take responsibility for safeguarding the patient care process. By taking such steps and implementing tools like a surgery checklist, we will improve patient and employee satisfaction, team collaboration, as well as dramatically change outcomes in surgery.

Dr. Martin November, Chief Medical Officer
Dr. November is an OB/GYN physician and was a member of the teaching faculty at Harvard Medical School for more than 10 years. He held various administrative positions at the Beth Israel Deaconess Medical Center including Director of the Division of Community Medicine. His academic research focused on patient safety, cost effectiveness analysis, and process improvement in healthcare. He worked with researchers at the Harvard School of Public Health on The Malpractice Insurers’ Medical Error Prevention Study (MIMEPS), a nationwide study of malpractice claims and medical errors. Prior to joining APS in 2008, Dr. November worked with the Harvard Business School Healthcare Initiative to develop the first Harvard Business School Health Science and Business Immersion Program in January 2006. He earned a Bachelor of Arts degree at Duke University, a Doctor of Medicine degree at the University of North Carolina at Chapel Hill, and a Master of Business Administration degree at the Harvard Business School.