July 1, 2008
WHO’s New Surgical Safety Checklist
It is fitting that co-author Atul Gawande played a key role in rolling out this tool that undoubtedly will prove to be very useful in reducing adverse events related to surgery. Most of you are very familiar with Dr. Gawande’s published works in the peer-reviewed literature. But perhaps his best know publication was his treatise on “The Checklist” 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. Gawande and his colleagues have run with that concept and developed a tool that can be applied to surgery throughout the world. Piloting the checklist at 8 sites worldwide, they demonstrated that adherence to several standards of surgical care were improved from 36% to 68%. Some hospitals achieved almost 100% adherence. Their preliminary data (in 1000 patients) suggests that there will be significant reductions in surgical morbidity and mortality.
The checklist has 3 phases:
At each phase, a designated Checklist coordinator must confirm that all steps/tasks have been completed before the patient moves on to the next phase. That coordinator could be any member of the team, though it is anticipated a circulating nurse may fulfill this role in many organizations.
During the Sign In phase (done before induction of anesthesia), the patient identity, site, procedure, and informed consent are confirmed. The site marking is confirmed and completion of the anesthesia safety check is done. The presence of a pulse oximeter on the patient and that it is functional are confirmed. Other issues addressed are allergies, airway risk, aspiration risk, risk of blood loss, and presence of proper equipment/assistance to help in these cases.
The Time Out phase is done before the skin incision. All team members introduce themselves by name and role. The team again confirms the identity of the patient, site, and procedure and discusses anticipated critical events. Also confirmed are antibiotic prophylaxis and timing and display of imaging studies.
The Sign Out phase is completed before the patient leaves the operating room. The Checklist coordinator verbally confirms the name of the procedure, the instrument and sponge counts, correct labeling of any specimens, any equipment problems, and key concerns for postoperative care and recovery.
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.
Note that the importance of checklists has also made its way into the Joint Commission’s National Patient Safety Goals (see our July 2008 What’s New in the Patient Safety World column “Joint Commission 2009 National Patient Safety Goals”).
Update: See our January 20, 2009 Patient Safety Tip of the Week “Checklists and Wrong Site Surgery”.” and our September 23, 2008 Patient Safety Tip of the Week “
WHO Surgical Safety Checklist
Weiser TG, Regenbogen SE, Thompson KD, Haynes AB, Lipsitz SR, Berry WF, Gawande AA. An estimation of the global volume of surgery: a modelling strategy based on available data. Lancet 2008 (early online publication 25 June 2008)
Gawande Atul. The Checklist. If something so simple can transform intensive care, what else can it do? The New Yorker. December 10, 2007