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The Checklist

Each year an estimated 234 million operations are performed throughout the world. Associated surgical complications account for a substantial burden of disease. The Toronto General Hospital (UHN) Department of Surgery participated in a prospective study of the impact of a Safe Surgery checklist, sponsored by the World Health Organization (WHO). The study included eight hospitals in a variety of settings - Jordan, India, Tanzania, the Philippines, Seattle WA, London UK, Auckland NZ and Toronto. 3733 patients were enrolled during a baseline period. The rates of mortality and complications were 1.5% and 11%. Following the introduction of a checklist designed and implemented by the investigators, these rates fell to 0.8% for death and 7% for complications in the next 3955 patients. A full presentation of the findings was published in the New England Journal of Medicine in January 2009. (1)

Last year, Lorelei Lingard, Glenn Regehr, Richard Reznick and their colleagues published a study of the impact of a checklist on communication in the operating room. They used a simple, clear design: observe, introduce, then observe and compare. (2) The checklist improved communication, collaboration and safety. WHO approached Richard Reznick to join a cohort study of the effect of a surgical checklist on complications of elective surgery. Richard proposed Toronto General Hospital as one of the clinical sites for the study. Bryce Taylor assumed the leadership role in this initiative and with the enthusiastic support of Chief Executive Officer Bob Bell the study was activated in November of 2007. Anne Slater, Richard's able executive assistant was seconded to manage the data.

Richard feels that this is "a defining paper that shows that lives can be saved through the use of the checklist. It is not definitive because it does not show how the lives were saved. It is also defining because it takes down hierarchical boundary lines, especially communication boundaries in the operating room. The impact of the checklist might be greater in settings where surgery is conducted on a production line model - where the surgeon doesn't meet the patient until she enters the operating room." Combat zones, specialized high volume surgery centres and less developed countries might show a greater benefit. Nevertheless, in Auckland, London, Seattle and Toronto the effect on complications was highly significant, though not as profound as it was in the lower income venues.

The checklist was quickly accepted thanks to the efforts of Bryce Taylor and Anne Slater, and is now standard procedure at Toronto General. The Ontario Hospital Association, the Canadian Surgical Chairs, and the Canadian Patient Safety Institute have all agreed to adopt it. Bryce Taylor attended the meeting in Geneva in which the eight surgical groups finalized the research plan. Bryce praises Anne for her effectiveness in gathering the data and completing the follow-up. Bryce's role was "to spread the word, prod and encourage participation". The strong endorsement of Bob Bell proved particularly helpful to this effort. Bryce will give talks across the country to disseminate the findings. "We had passion, persistence and persuasion before. Now we have proof. Though we can't prove that mortality was decreased in high-income centres, the complication rate was significantly reduced. We can protect 60,000 patients per year in Canada based on the overall 4% reduction in complications. (4.9% in low-income centres and 3.1% in high-income centres.) Our goal is to make the checklist as automatic as putting on the seatbelt in your car."

Seatbelts save lives, take little effort and don't cost very
much. Some surgeons now say that they don't feel right unless they complete the checklist before starting the case, just as they don't feel comfortable driving unless they use a seatbelt.

Adrian Boelen a retired pilot in Dorval wrote a sobering letter to the National Post: "Checklists in aviation have been in use pretty well since the Wright brothers. One wonders whether such checklists would have been introduced much earlier in medicine if surgeons shared the fate of their patients, as pilots share that of their passengers."

The authors and commentators on the study raised the question whether the improvement is related to the Hawthorne effect - the tendency for people to improve their behaviour when they know that they are being watched. Bryce answers that this is an intensified variation on the Hawthorne effect. Everyone was aware that a detailed number of important factors were being observed and recorded. This knowledge, that data were being collected, automatically improved behaviour and improved outcome. "Observed behaviour is improved behaviour." He asks: "if you had an operation scheduled for tomorrow, would you want the operation to be done without the checklist? It is cheap, easy, takes two minutes to do and reduces complications. Shouldn't we be the first university to incorporate the checklist in all of our hospitals so that every resident will learn to incorporate the checklist as an essential component of every surgical operation?"

Anne Slater was responsible for collecting and recording all of the data for both phases of this study. She started with orientation of the nurses, trainees and surgeons at 6:45 each morning. Gillian Gravely, nurse manager of the operating room, introduced her to the nurses and operating room staff. Anne put the checklist questionnaire on fluorescent lime green sheets on the front of each chart. She recorded much of the data from the charts, working within the system to make it easier for the nurses and surgeons. This approach assured her welcome as part of the operating room team, rather than as a stranger or inspector. The baseline period ran for two months starting in November 2007. The second phase, after the checklist had become a routine part of care, began in March 2008 and finished in May 2008. "People got used to it; the checklist was stuck on the door near the clock in a big plasticized sign." The postintervention phase went well as the fellows and nurses were all accustomed to the use of the checklist. Resident turnover was somewhat of a confounding variable. The nurses liked the system; they felt it built team spirit. Some surgeons ran through the checklist as a humourous skit and a fun way to introduce new people in the operating room. Though there were some resisters, no annoyance was detectable. "Though the list looks big, it takes only 2-3 minutes to fill out." The patients felt safer and were pleased that the checklist was in place. Anne's background as a research nurse working with Steve Wolman at Toronto General proved excellent preparation for this project. She was familiar with checklists used in aviation as her father was a pilot and her son Mike, an army captain in armoured reconnaissance is also a pilot. Anne serves as an executive assistant to Richard Reznick in his role as Vice President, Education at UHN. She manages a broad portfolio, orchestrates multiple teleconferences, helps in the clinic and manages novel initiatives such as the checklist project. Anne is married to Michael, an executive chef. Like most surgeons, she is a morning person, hitting the gym at 6:30 each morning when she is not in the operating room. She runs half marathons and skis. In addition to its usefulness, she found the checklist project stimulating and fun.

Let's be the first department in Canada to integrate the checklist as an essential element of training and care at all of our hospitals.


(1) Hayes AB, et al. A Surgical Safety Checklist to Reduce Morbidity and Mortality in a Global Population. New England Journal of Medicine Jan. 29, 2009;360(5):491-499

(2) Lingard L, Regehr G, Orser B, Reznick R, et al. Evaluation of a Preoperative Checklist and Team Briefing Among Surgeons, Nurses, and Anesthesiologists to Reduce Failures in Communication. Archives of Surgery. Jan. 2008;143(1):12-17.

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