What’s New in the Patient Safety World

May 2019

WHO Surgical Safety Checklist Cut Mortality 37% in Scotland

 

 

We’re, of course, big fans of the use of checklists in healthcare. We’ve done several columns on the successes of the WHO Surgical Safety Checklist. Our July 1, 2008 Patient Safety Tip of the Week “WHO’s New Surgical Safety Checklist” described the tool and provided the link to download the checklist tool and instructions how to use it.  We also discussed checklist design and use in our September 23, 2008 Patient Safety Tip of the Week “Checklists and Wrong Site Surgery”.

 

In our January 20, 2009 Patient Safety Tip of the Week “The WHO Surgical Safety Checklist Delivers the Outcomes” we discussed the striking improvements in patient outcomes following implementation of the WHO Surgical Safety Checklist at hospitals in eight different countries. Haynes and colleagues (Haynes 2009) demonstrated that mortality at 30-days post-op decreased from 1.5% before introduction of the checklist to 0.8% after. Rate of any complication decreased from 11% to 7%. Both these outcomes were highly statistically significant. That’s a relative risk reduction of approximately 36% for mortality and major morbidity!

 

But, in our April 2014 What's New in the Patient Safety World column “Checklists Don’t Always Lead to Improvement” we noted a study that showed, despite widespread adoption in over 100 hospitals in Ontario, Canada, a surgical checklist failed to demonstrate significant reductions in adjusted rates for mortality or complications (Urbach 2014). The rate of any complication decreased from 3.86% to 3.82% and mortality at 30-days post-op decreased from 0.71% to 0.65% in Canadian study, neither being statistically significant. There was also no significant changes in rates of hospital readmission and emergency department visits within 30 days after discharge. This result was surprising, especially since self-reported compliance with the checklist was over 90% at almost all participating hospitals. We discussed some of the reasons that study may have failed to demonstrate significant improvement after implementation of the checklist.

 

But in that April 2014 What's New in the Patient Safety World column “Checklists Don’t Always Lead to Improvement” we also noted several other examples where the WHO Surgical Safety Checklist or similar checklists have led to substantial improvements in perioperative outcomes. We also noted other studies demonstrating improvements after implementation of the Surgical Safety Checklist in our What's New in the Patient Safety World columns for May 2015 “The Great Checklist Debate” and May 2017 “Another Success for the Safe Surgery Checklist”.

 

Now another study from Scotland (Ramsay 2019) showed that implementation of the WHO Surgical Safety Checklist produced striking improvement in mortality. The WHO Surgical Safety Checklist was implemented in Scotland as part of a broader patient safety initiative between 2008 and 2010, Analyzing almost 7 million surgical cases between 2000 and 2014, the researchers found a 37% reduction in mortality. There was no such improvement trend for non-surgical cases over the same timeframe. While some improvement may have been related to other factors, the authors attribute the striking success to adoption of the WHO Surgical Safety Checklist.

 

Of course, implementing a checklist does not guarantee that it will be fully adhered to. In commenting a Norwegian study (Haugen 2015), several of the coauthors of the original WHO study pointed out that the Norwegian study showed a “dose effect” in that larger reductions in complications were seen when all portions of the checklist were followed (Haynes 2015).

 

We hope you’ll look at some of the recommendations about how to implement checklists in our November 20, 2018 Patient Safety Tip of the Week “Checklist Implementation” and our many prior columns on checklists listed below.

 

 

Some of our prior columns on checklists:

• June 5, 2007 “Patient Safety in Ambulatory Surgery”
• July 24, 2007 “Serious Incident Response Checklist”
• March 11, 2008 “Lessons from Ophthalmology”
• July 1, 2008 “WHO’s New Surgical Safety Checklist”
• September 23, 2008 “Checklists and Wrong Site Surgery”
• November 18, 2008 “Ticket to Ride: Checklist, Form, or Decision Scorecard?”
• November 25, 2008 “Wrong-Site Neurosurgery”
• January 20, 2009 “The WHO Surgical Safety Checklist Delivers the Outcomes”  
• January 19, 2010 “Timeouts and Safe Surgery”
• June 2010 “WHO Checklist for Radiological Interventions”
• June 8, 2010 “Surgical Safety Checklist for Cataract Surgery”
• July 6, 2010 “Book Reviews: Pronovost and Gawande”
• September 14, 2010 “Wrong-Site Craniotomy: Lessons Learned”
• November 30, 2010 “SURPASS: The Mother of All Checklists”
• December 6, 2010 “More Tips to Prevent Wrong-Site Surgery”
• February 2011 “SURPASS Checklist Reduces Malpractice Claims”
• March 2011 “Michigan ICU Collaborative Wins Big”
• June 6, 2011 “Timeouts Outside the OR”
• August 16, 2011 “Crisis Checklists for the OR”
• July 2012 “VA Checklist Reduces Suicide Risk”
• July 2012 “WHO Safe Childbirth Checklist”
• October 2012 “Another PCA Pump Safety Checklist”
• February 2013 “Checklists for Surgical Crises”
• April 2014 “Checklists Don’t Always Lead to Improvement”
• May 2015 “The Great Checklist Debate”
• August 25, 2015 “Checklist for Intrahospital Transport”
• September 1, 2015 “Smarter Checklists”
• September 15, 2015 “Another Possible Good Use of a Checklist”
• September 13, 2016 “Vanderbilt’s Electronic Procedural Timeout”
• November 2016 “Oxygen Tank Monitoring”
• November 1, 2016 “CMS Emergency Preparedness Rule”
• January 10, 2017 “The 26-ml Applicator Strikes Again!”
• May 2017 “Another Success for the Safe Surgery Checklist”
• May 2, 2017 “Anatomy of a Wrong Procedure”
• June 2017 “Another Way to Verify Checklist Compliance”
• August 22, 2017 “OR to ICU Handoff Success”
• November 28, 2017 “More on Dental Sedation/Anesthesia Safety”
• December 12, 2017 “Joint Commission on Suicide Prevention”
• December 19, 2018 “More on Overlapping Surgery”
• February 2018 “Oxygen Cylinders Back in the News”
• October 30, 2018 “Interhospital Transfers”
• November 20, 2018 “Checklist Implementation”

 

 

 

References:

 

 

WHO Surgical Safety Checklist

http://www.who.int/entity/patientsafety/safesurgery/tools_resources/SSSL_Checklist_finalJun08.pdf

 

 

Haynes A, Weiser T, Berry W, et al. A surgical safety checklist to reduce morbidity and mortality in a global population. N Engl J Med 2009; 360(5): 491-499

http://www.nejm.org/doi/full/10.1056/NEJMsa0810119#t=articleTop

 

 

Urbach DR, Govindarajan A, Saskin R, et al. Introduction of Surgical Safety Checklists in Ontario, Canada. N Engl J Med 2014; 370: 1029-1038

http://www.nejm.org/doi/full/10.1056/NEJMsa1308261

 

 

Ramsay G, Haynes AB, Lipsitz SR, et al. Reducing surgical mortality in Scotland by use of the WHO Surgical Safety Checklist. British Journal of Surgery 2019; Early access 16 April 2019

https://onlinelibrary.wiley.com/doi/10.1002/bjs.11151

 

 

Haugen AS, Søfteland E, Almeland SK, et al. Effect of the World Health Organization Checklist on Patient Outcomes: A Stepped Wedge Cluster Randomized Controlled Trial. Annals of Surgery 2015; 261(5): 821-828

http://journals.lww.com/annalsofsurgery/Fulltext/2015/05000/Effect_of_the_World_Health_Organization_Checklist.1.aspx

 

 

Haynes AB, Berry WR, Gawande AA. What Do We Know About the Safe Surgery Checklist Now? Annals of Surgery 2015; 261(5): 829-830

http://journals.lww.com/annalsofsurgery/Fulltext/2015/05000/What_Do_We_Know_About_the_Safe_Surgery_Checklist.2.aspx

 

 

 

 

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