September 23, 2008
Checklists and Wrong Site Surgery
Headlines continue to highlight cases of wrong site surgery. In the last few months, cases have even occurred at well-respected academic facilities such as the Beth Israel Hospital in Boston and the Miriam Hospital in Rhode Island. In the former case, a surgical timeout apparently did not take place. In the latter, the error occurred despite a surgical timeout. It is not clear whether either organization utilizes the checklist approach that we strongly advocate.
Joint Commission’s 2009 National Patient Safety Goals (see our July 2008 What’s New in the Patient Safety World column “Joint Commission 2009 National Patient Safety Goals”) have a requirement for use of a checklist during the pre-procedure verification process. The checklist can be paper or electronic or even on a wall-mounted white board and needs to include elements such as the H&P, anesthesia assessment, completed informed consent, appropriate diagnostic and imaging reports or images, and any required implants, devices, special equipment or blood products that will be needed.
WHO’s new Surgical Safety Checklist (see our July 2, 2008 Patient Safety Tip of the Week “WHO’s New Surgical Safety Checklist”) actually consists of 3 checklists, one for the period prior to induction of anesthesia, one for the timeout (prior to skin incision), and one before the patient leaves the OR. The Checklist and a short manual on how to best use it can both be downloaded from the WHO website. Facilities are encouraged to modify the Checklist and add safety steps that are important to their needs, though removal of any steps is discouraged. Modification of the Checklist for specific procedures is likely to occur, for instance confirmation of specific DVT prophylaxis for many specific procedures. Yet the beauty of the Checklist is its simplicity and the authors’ caution against making it too complex.
But even more comprehensive checklists have been developed for specific surgical settings. Use of a 28-item structured checklist (Verdaasdonk 2008) addressing problems with laparoscopic equipment resulted in a 53% reduction of incidents related to such equipment.
A few weeks ago, at one of our patient safety presentations, a surgeon expressed concern about the amount of time added to procedures by following Universal Protocol and doing the surgical timeout. The answer is that following the protocol in most cases adds no more than 1-2 minutes per case. Even in the busiest of OR’s that does not add a significant burden to the OR schedule. The beauty of checklists is that they are both simple and save time in the long run. Even the 28-item laparoscopic checklist in the Verdaasdonk article took only an average of 3.3 minutes to complete. Though they did not specifically measure it, we suspect that there was far more time savings on the back end, i.e. the time saved by avoiding equipment problems probably far exceeded the 3.3 minutes taken on the front end.
One important point to remember is that developing checklists is not enough. You must audit the use of and adherence to the checklists you develop. Some organizations do video monitoring of surgical procedures, including recording of the timeout procedure. That allows analysis of the completeness of the surgical timeout and can be a valuable tool in promoting a culture of safety and improving communication within the OR. Other organizations are too fearful of litigation to do video recording. Those organizations should at least perform sample audits of the timeout procedure (by having someone in the OR audit the timeout) but those need to be done in a manner in which the presence of the auditor does not bias the procedure. Walking into the OR and announcing “I’m here to audit the timeout” almost guarantees that timeout will be done correctly. While we advocate openness and frankness in quality improvement activities, sometimes a “secret shopper” type audit needs to be done to get a true picture of how often the timeout is being done and being done properly and completely. The audit should be done for anything you develop a checklist for, not just a safe surgery checklist.
Atul Gawande, a coauthor of the WHO checklist may be best known for his treatise on “” that appeared in The New Yorker. In that article, he eloquently expounded upon the simplicity and sophistication of Peter Pronovost’s success in introducing the concept of the checklist to improve medical care. We recommend use of checklists for multiple different types of processes in healthcare such as:
Checklists can also be a part of your own personal life. We have a little cabin on an island in northern Ontario. It takes 6-7 hours to get there so anything we overlook either when we are going there or coming back can lead to major problems. So we use checklists! We have one for all the things we need to make the trip up there and another for all the things we need to do when we are leaving the cabin. We even have a checklist for inventory of common items we keep at the cabin. Sometimes time pressures (there’s a thunderstorm coming in – let’s get going!) have caused us to shortcut the checklist. Almost invariably when we skip things on the checklist it comes back to haunt us. So we’ve learned the hard way – if you make a check list, use it correctly!
Checklists are some of the most valuable tools we have available in quality improvement and patient safety. They are also the least expensive of all tools. But the ROI on checklists is incredibly high, both in human terms and financial terms.
The Verdaasdonk article also references an excellent guidance from the UK Civil Aviation Authority on the proper design, presentation and use of checklists.
Update: See our January 20, 2009 Patient Safety Tip of the Week “”.
Joint Commission. 2009 National Patient Safety Goals.
WHO Surgical Safety Checklist
Verdaasdonk EG, Stassen LP, Hoffman WF, van der Elst M, Dankelman J. Can a structured checklist prevent problems with laparoscopic equipment. Surgical Edoscopy 2008; 22: 2238-2243 (accessed online 9/22/2008) http://www.springerlink.com/content/1845j684574501v2/
Gawande Atul. The Checklist. If something so simple can transform intensive care, what else can it do? The New Yorker. December 10, 2007
Civil Aviation Authority (UK). CAP 676: Guidance on the Design, Presentation and Use
of Emergency and Abnormal Checklists. January 2006.