By James Wright, MD, MPH, FRCSC
It's not that the pilot doesn't know what she's doing when she goes through the pre-flight checklist with the crew before
takeoff. It's just that there is a lot to remember and the checklist helps make sure that no errors are made — errors that
might prove catastrophic 30,000 feet in the air.
Going through a checklist before embarking on some complex task, like operating a jet airliner with 500 passengers aboard,
makes a lot of sense. Engineers do it, software developers do it, even military officers rely on the "aide memoire," literally
a "memory aid," to make sure needless, and perhaps deadly, mistakes are avoided when giving orders.
Checklists save lives. And now, the expanding use of surgical checklists is poised to make a difference on the operating table.
The World Health Organization (WHO) estimates that over a quarter of a billion major surgeries are performed every year. While
undoubtedly the vast majority of these surgeries save and improve lives, according to many studies, some result in preventable
complications and deaths. The key word here is "preventable," and that's where checklists come in.
Surgical checklists
There are several types of checklists, each usually identified with one of the three phases of an operation:
In each phase, a coordinator confirms that specific tasks have been completed by the surgical team before going on with the
next phase.
For example, during the "sign in" phase, the coordinator, among other things, confirms the identity of the patient, the correct
site to be operated on, and that the right procedure is about to be preformed. The idea is to avoid operating on the wrong
patient, the wrong site, or performing the wrong procedure.
During the "sign out" phase, instruments, sponges, and needles are counted to check that none of these is accidentally left
behind in the patient's body.
Many hospitals have been using some form of the surgical checklist for years. Confirming the right patient, right site, and
right procedure before an operation is so simple, it's difficult to imagine errors are actually reduced in the surgical suite
this way. But new data from the WHO suggests surgical checklists do reduce the errors.
In 2008, the WHO created a standardized set of surgical checklists and tried them out in eight locations around the world.
Mortality dropped from 1.5% to 0.8% and complications dropped from 11% to 7%. The results suggest if these checklists were
implemented around the globe, millions of surgical complications and lives lost could be avoided every year.
Not reflected in the data are the reasons why checklists work; however, it is thought there is more going on than simply ticking
a box and avoiding a very dumb mistake. The authors of the study concede that the improved outcomes may be partly due to the
"Hawthorne effect," the phenomenon that people usually perform better when they know they are being watched. Another thought
is that going through a checklist promotes teamwork and increased communication in the operating room, making the possibility
of error more remote in general.
The experience at SickKids: huddles and time outs
In 2005, the 07:35 Huddle, a surgical team meeting prior to the day's cases, was introduced at SickKids. The Huddle is rather
like a "sign in" checklist, though it is a single briefing for all the cases of the day. One goal of the huddle is to encourage
team members, including surgeons, anaesthetists, and nurses, to speak out if they believe a safety issue has emerged.
A year later, we introduced a surgical "time out" to complement the Huddle. Done after anaesthesia but before an incision
is made, the time out confirms the identity of the patient, the site for the surgery, and the procedure to be performed. The
time out also confirms all the proper equipment is there for the procedure and that all medication, including antibiotics,
has been administered.
Now, after a few years of using the checklists, collecting data about their effect, and comparing this to data gathered before
checklists were introduced, some conclusions can be made about the experience at SickKids.
First, major surgical errors were completely eliminated. While this is certainly good news, SickKids had a near-perfect track
record in this regard before the checklists were used.
Second, it was found that using the checklists changed the perceptions of many members of the surgical team about safety and
communication. Nurses felt the checklist improved communications and encouraged staff to voice potential problems and safety
concerns to the others in the room. However, the same could not be said of the surgeons, some of whom weren't certain the
checklists would improve safety.
Exactly why some doctors were not as enthusiastic is not known, but it is likely they simply didn't feel the need for the
improved communication that checklists enable. Perhaps it was a case of not putting themselves into the other's shoes. Regardless,
in the last four years, checklists have become a fixture at SickKids because they have demonstrable value for patients and
staff.
Given these results, SickKids plans on staying the course with checklists. The only foreseeable change will be the introduction
of a paediatric "post-surgical briefing" which will bring the hospital more in line with the WHO's three checklist recommendations.
Dr. James G. Wright is Surgeon-in-Chief, Robert B. Salter Chair of Pediatric Surgical Research, and Senior Scientist, Population
Health Sciences at The Hospital for Sick Children (SickKids). He is also a professor in the Departments of Surgery, Public
Health Sciences, and Health Policy, Management, and Evaluation at the University of Toronto.
