Patient Safety Tip of the Week

November 30, 2010

SURPASS: The Mother of All Checklists



Regular readers of this column know we’re strong advocates of using checklists. See our January 20, 2009 Patient Safety Tip of the Week “The WHO Surgical Safety Checklist Delivers the Outcomes” and our September 23, 2008 Patient Safety Tip of the Week “Checklists and Wrong Site Surgery”.


Now the results of implementation of the most comprehensive checklist we have ever seen, the SURPASS (SURgical PAtient Safety System) checklist, have been published (de Vries 2010a). The SURPASS checklist, which covers almost every process from the preadmission phase through the post-discharge period, was implemented at 6 Netherlands hospitals. Though a randomized controlled methodology was not feasible, a pre/post-implementation comparison methodology was used with a comparable control group being 5 other high-performing Netherlands hospitals. At the intervention hospitals, the total number of complications per 100 patients decreased from 27.3 to 16.7 and in-hospital mortality decreased from 1.5% to 0.8%.


You’ll recall from our January 20, 2009 Patient Safety Tip of the Week “The WHO Surgical Safety Checklist Delivers the Outcomes” that mortality at 30-days post-op decreased from 1.5% before introduction of the WHO checklist to 0.8% after and the rate of any complication decreased from 11% to 7% (Haynes 2009).


So how does this differ from the results of implementing the WHO Surgical Safety Checklist? Probably the biggest difference was that all the hospitals in the Netherlands study were ones already performing at high levels. The other is that the SURPASS checklist is far more comprehensive and covers the entire surgical experience for a patient, not just the immediate perioperative period. Of course, some might argue, that comparable results were attained just using the shorter WHO surgical safety checklist so why should we use the much longer SURPASS checklist? You’ll have to answer that yourselves but when we look at all the important items included on the SURPASS checklist, we’d certainly opt for that.


Keeping with good design of checklists (see below), SURPASS is really a series of much shorter checklists, each of which contains items that could be easily overlooked if one were counting on memory alone. Also, it does not contain many items that would seldom be overlooked. Each component checklist requires signing off (and dating) by the appropriate person(s).


A good flowchart of the surgical process with notation of where each checklist is used is available on the SURPASS website. The SURPASS checklist begins on the day prior to surgery. Not only does it prompt to check that all the instruments, equipment and implants that will be needed are present but it also prompts a double check that all information in the OR schedule is correct (requiring discussion with the surgeon if there is any doubt).


Next is a preoperative checklist to be completed by the physician on the ward before the patient is transported to the surgical holding area. Here the physician (if different that the surgeon) must acknowledge that he/she has seen the patient and that all necessary clinical materials, including all lab and imaging studies, are available and that all relevant recommendations from consultants and anesthesiology have been carried out. This is particularly important since we have seen cases where a consultant orders a test and the surgeon, anesthesiologist, and consultant all think the test was reviewed by one of the others and no one actually reviews that test result. The physician also ensures that medications are ordered (eg. prophylactic antibiotics) and that anticoagulants have been discontinued if appropriate. It also prompts the physician to schedule an ICU bed if necessary.


A separate checklist for the surgeon is to be completed on the ward prior to transport to the surgical holding area. This one acknowledges that the surgeon has seen the patient and obtained informed consent, that all the data and information on the OR schedule is correct, and that he/she has discussed with the patient and marked the operative site. It also has items regarding comorbidities and allergies in those cases where an anesthesiologist will not be involved.


The anesthesiologist is also to see the patient on the ward prior to transfer to the holding area. His/her checklist reiterates many of the items on earlier checklists (all clinical and lab results, consultant recommendations, medications, allergies, etc.). He/she confirms that the completed informed consent is in the chart and orders any necessary premedications. He/she discusses with the patient the anesthesia technique planned and any alternatives.


Similarly, prior to transport to the holding area, the ward nurse completes a checklist. This one includes assessments for decubiti, falls, delirium (we love it! Wish US hospitals would do it!), and nutrition. The nurse preps the patient according to protocols and ensures that orders and clinical information are in the chart. She/he also checks that appropriate identification tags/bracelets are on the patient and removes dentures, etc. Lastly, the nurse confirms that the physician’s checklist has been completed.


Next, in the OR the time out is done with the surgeon, anesthesiologist, anesthesia assistant, and operating assistant as a group. It contains most of the same items we would do under Universal Protocol or the WHO surgical safety checklist (correct patient, procedure, site, implants, prophylactic antibiotics given, patient positioning, presence of imaging studies and blood products, anesthesia equipment, instruments, etc.).


On completion of the surgery another series of checklists is completed prior to transfer to the post-op recovery area, One for the surgeon includes instructions regarding fees, tubes, drains, and other post-op needs. One for the anesthesiologist includes detains about fluid management, analgesics and other medications, ventilation, oxygen, and clinical and laboratory monitoring parameters.


Next is one completed by the anesthesiologist or intensivist prior to transfer to the ward or ICU. This confirms that the patient has met criteria for discharge from the PACU and includes communication to the next set of caregivers regarding analgesics, other medications, fluids, diet, oxygen, monitoring parameters, wound care, and any other special instructions.


The penultimate checklist is done prior to discharge. It has a section to indicate that the physician has discussed the pathology with the patient, plus instructions regarding wound care, drains/tubes, diet, anticoagulants, etc. It ensures that medication reconciliation takes place and that all followup appointments have been arranged and that the discharge summary has been completed and sent to the next caregiver.


The final checklist is completed by the ward nurse. It confirms that the above checklist was completed by the physician and repeats most of the same elements that the physician completed at discharge.


The SURPASS checklist is not an easy implementation. 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).


Some other very good articles on checklist design are available (Verdaasdonk 2008, Verdaasdonk 2009). Our July 6, 2010 Patient Safety Tip of the Week “Book Reviews: Pronovost and Gawande” had some key points on checklist design from Atul Gawande’s book “The Checklist Manifesto: How to Get Things Right”. The Verdaasdonk articles also reference an excellent guidance from the UK Civil Aviation Authority on the proper design, presentation and use of checklists. We also discussed checklist design and use in our September 23, 2008 Patient Safety Tip of the Week “Checklists and Wrong Site Surgery”.


Other 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. And Lingard et al (Lingard 2008) used a checklist to structure short team briefings and documented both reduction in the number of communication failures and other utility of the intervention.


Individual checklists generally take only minutes to complete. 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.


As per our prior articles on checklists, we do advocate doing periodic audits of compliance with the checklists in toto and compliance with individual components of the checklist. In the SURPASS study, complication rates were generally lower in those cases where compliance with the checklists were higher.


The SURPASS checklist does help ensure that evidence-based care gets implemented. A previously reported study showed the use of the SURPASS checklist leads to better compliance with regard to the timing of antibiotic prophylaxis administration (deVries 2010b). But its real value is probably in fostering teamwork, communication, and handoffs. Perhaps the biggest debate in both the SURPASS study and the WHO study 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.






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


the SURPASS checklist


Haynes AB, Weiser TG, Berry WR, et al. for the Safe Surgery Saves Lives Study Group. A Surgical Safety Checklist to Reduce Morbidity and Mortality in a Global Population. N Engl J Med. Online First January 14, 2009 (DOI: 10.1056/NEJMsa0810119), in Print January 29, 2009



flowchart of the processes in SURPASS



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



Verdaasdonk EGG, Stassen LPS, Widhiasmara PP, Dankelman J. Requirements for the design and implementation of checklists for surgical processes. Surg Endosc (2009); 23: 715–726



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)



Gawande A. The Checklist Manifesto: How to Get Things Right. Metropolitan Books 2010



Civil Aviation Authority (UK). CAP 676: Guidance on the Design, Presentation and Use

of Emergency and Abnormal Checklists. January 2006.



Lingard L, Regehr G, Orser B, Reznick R, Baker GR, Doran D, Espin S, Bohnen J, Whyte S. Evaluation of a Preoperative Checklist and Team Briefing Among Surgeons, Nurses, and Anesthesiologists to Reduce Failures in Communication. Arch Surg, Jan 2008; 143: 12-17



de Vries EN, Dijkstra L, Smorenburg SM, et al. The SURgical PAtient Safety System (SURPASS) checklist optimizes timing of antibiotic prophylaxis. Patient Safety in Surgery 2010; 4: 6
















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