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What’s New in the Patient Safety World

June 2020

Are Two Checklists Better Than One?



Yes, we’re still big fans of checklists. We’ve done many columns on the WHO Surgical Safety Checklist and a few on the SURPASS Checklist. But now a study has been done in which the addition of the preoperative and postoperative SURPASS checklists to the WHO Surgical Safety Checklist further reduced complications, reoperations, and readmissions.


The study (Storesund 2020) was nonrandomized and consisted of a stepped-wedge cluster clinical trial at 3 Norwegian tertiary care hospitals. The WHO surgical safety checklist (WHO SSC) was already in use at the hospital. The preoperative and postoperative SURPASS checklists were implemented then in 3 surgical departments (neurosurgery, orthopedics, and gynecology), serving as their own controls, and three surgical units offered additional parallel controls.


Adherence to the preoperative SURPASS checklists was associated with reduced complications (odds ratio 0.70; P = .04) and reoperations (OR 0.42; P = .004). Adherence to the postoperative SURPASS checklists was associated with decreased readmissions (OR 0.32; P = .001). No changes were observed in mortality or LOS. In parallel control units, complications increased (OR 1.09; P = .04), whereas reoperations, readmissions, and mortality remained unchanged.


The WHO Surgical Safety Checklist is used in the operating room. So, it would be logical to add checklists that cover the preoperative and postoperative periods as well. Quite frankly, we were surprised there had been no prior publications on use of the combined checklists.


The WHO Surgical Safety Checklist has been shown in multiple studies to reduce complications and, in some studies, reduce mortality as well. Not all studies have demonstrated such improvement but those that did not usually had suboptimal adherence to all components of the checklist or were already functioning at a very high level and incorporating most of the quality and patient safety concepts engendered by the checklist.


We’ve also noted that the SURPASS (SURgical PAtient Safety System) checklist reduces complications and mortality (de Vries 2010) (see our November 30, 2010 Patient Safety Tip of the Week “SURPASS: The Mother of All Checklists” and our February 2011 What's New in the Patient Safety World column “SURPASS Checklist Reduces Malpractice Claims”). We called SURPASS “the mother of all checklists” because of its comprehensive content. But it is really a series of shorter checklists. It is not an easy implementation. In our November 30, 2010 Patient Safety Tip of the Week “SURPASS: The Mother of All Checklists” we noted that in one study it took, on average, 6 to 9 months to implement at each hospital. De Vries and colleagues previously discussed the development  and validation of the SURPASS checklist (de Vries 2009).


Checklists, of course, are good tools for ensuring that we remember to perform or consider items that are important to whatever processes we are using them for. But implementing checklists involves more than simply putting a bunch of items together on paper. The real value of many checklists is in fostering teamwork, communication, and handoffs. Perhaps the biggest debate in studies of both the SURPASS checklist and the WHO checklist is whether the striking improvements are attributable to use of the checklist per se or to the change in “culture” that accompanied use of the checklist. Again, to that debate we say “who cares?”. If merely using a checklist results in such powerful improvement in the culture of safety and promotion of better communication and teamwork, use it!!!


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 current study also serves as a reminder that we can’t just focus on one aspect of surgery. Rather, it is important we manage the patient throughout the entire perioperative period.



Some of our prior columns on checklists:






Storesund A, Haugen AS, Flaatten H, et al. Clinical Efficacy of Combined Surgical Patient Safety System and the World Health Organization’s Checklists in Surgery: A Nonrandomized Clinical Trial. JAMA Surg 2020; Published online May 13, 2020



de Vries EN, Hollmann MW, Smorenburg SM, et al. Development and validation of the SURgical PAtient Safety System (SURPASS) checklist. Qual Saf Health Care 2009; 18: 121-126



de Vries EN,  Prins HA, Crolla RMPH, et al. for the SURPASS Collaborative Group.Effect of a Comprehensive Surgical Safety System on Patient Outcomes. N Engl J Med 2010; 363: 1928-1937




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