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.
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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.
M.M.
(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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