Thursday, June 26, 2008

Surgical Checklist for Patient Safety

When a pilot sits in the cockpit, she methodically goes through a checklist of all systems and equipment before the plane is fired up. Even if the pilot has flown that plane and route 1000 times, the items on the checklist are reviewed one by one and no-one would think of flying the plane without completing the checklist.

Now, the World Health Organization (WHO) has developed a checklist to be used in the surgical suite by every surgical team before the patient is put to sleep. Up to 16% of surgical procedures result in an unexpected complication. The death rate from surgery in developing nations is an astonishing 10%. A study in Lancet found basic safety measures were overlooked in hospitals around the world.

One of my favorite medical writers is Atul Gawande, a surgeon and Harvard University professor. He worked with WHO and more than 200 worldwide medical organizations to create the checklist.

"What we identified, was that the idea of a checklist to make sure the basic steps are taken, could make a big difference not only in the poorest part of the world but even in the rich ones."
"We borrowed an idea that pilots have for 75 years," Gawande said. "It's like an airline check, you make it short, simple and the team can do better."

Its primary aim is to target the three biggest cause of mortality in surgery - preventable infections, preventable complication from bleeding, and safety in anesthesia.
It includes six basic steps in care, including verifying that it is the correct patient, ensuring equipment is not left inside the patient, and administering an antibiotic before making an incision - which cuts the risk of infection by half.

A study published in the Lancet, found that before the checklist was used there was a 64% chance that at least one of the procedures was forgotten - with no difference between rich and developing countries. However after implementing the checklist system, failure rates for the first 1,000 patients dropped by half to 32 percent. In a couple of place they cut it to 100 percent. More definitive results will be known later in the year after 3,500 major surgical interventions have been studied.
In the meantime three countries -- Britain, Ireland and Jordan -- have already adopted the checklist procedures in the operating rooms of their hospitals. I hope the USA follows soon.

WHO officials hope the checklist will be adopted around the world.


Brandon Wood said...

Very good post with great information Dr. Brayer. This actually won an honorable mention for this weeks Scrubby Awards on Congratulations!


Anonymous said...

I'm surpriesd tha US is not using these check lists now. What are we waiting for? I know thay do have nurses cross reading the patients braclet info. and blood type to match the unit of blood before blood transfusions. Another thing hospitals do is to x-ray before and after surgeries to make sure nothing was left in.

Jonathan said...

As a licensed pilot and (of course) a patient, I can’t tell you how happy I am to hear that the idea of the checklist has taken hold in the surgical suite, and that the initial results are promising.

If aviation safety is the model, then experience suggests that the next human foible to overcome will be a rote read-back confirming the item being checked without actually executing the item on the checklist; or a skipped item on the checklist; or perhaps even a failure to use the checklist. The annals of aviation safety are littered with the remains of those who failed to use their checklists properly. said...

Well, I don't really think it will work.