Checklist helps improve OR safety in just minutes
With hospitals all over the country realizing that there is a benefit in having the surgical team pause, take a breath, and double-check that everything is in order before proceeding, a hospital in Washington has formalized that process even more by using a checklist that the team can go through before starting the procedure. The simple procedure can have a major impact on patient safety, the hospital reports.
The Safe Surgery Saves Lives (SSSL) checklist has been used at the University of Washington Medical Center (UWMC) in Seattle for a year, and the hospital's experience s proves conclusively that inpatient deaths can be significantly reduced, along with the rate of major complications after surgery, by following a simple checklist, says Patchen Dellinger, MD, professor and vice chair of the department of surgery. The SSSL checklist was developed by the World Health Organization (WHO), and UWMC is the only U.S. hospital to participate in the pilot phase of the program. Researchers recently published results from the worldwide program showing substantial benefits.1
Analysis of studies undertaken in the eight hospitals showed that the rate of major complications fell from 11% in the baseline period to 7% after introduction of the checklist. At the same time, inpatient deaths following an operation fell by more than 40% with the implementation of the checklist. Dellinger says UWMC is seeing similar results, but the data still are being analyzed.
(Editor's note: More information on the SSSL project can be found online at www.who.int/patientsafety/safesurgery/en/. The SSSL surgical checklist can be found online at www.who.int/patientsafety/safesurgery/tools_resources/SSSL_Checklist_finalJun08.pdf.)
Surgical teams in the Division of General Surgery at UWMC began using the checklist in April 2008. Dellinger says complications related to surgery were significantly decreased after checklist implementation, and a survey conducted after the pilot phase of the project found that an overwhelming majority of personnel in UWMC operating rooms would want a checklist used if they were having an operation.
The checklist which is similar to lists used by pilots before takeoff takes only about two minutes to complete at three critical points during operative care: before anesthesia is administered, before skin incision, and before the patient leaves the operating room. Before a patient is rolled into the operating room, medical center staff ask the patient to confirm his or her identity and the procedure. Once in the operating room, all team members introduce themselves by name and role.
UW Medical Center, like many hospitals, had been using checklists in the OR for some time, but they were not uniform or used consistently. The SSSL checklist standardized the process and presented an opportunity to formalize how the checklist is used. The hospital created laminated posters of the checklist, measuring 2 feet by 3 feet, so they could be hung in every operating room. The checklists are easy to read from anywhere in the room.
"The checklists promote a good working relationship with the surgeons, the nurses, and the anesthesiologists," Dellinger says. "Anesthesiologists have had great success in recent years with using checklists to improve patient safety, and now this initiative helps all three groups to come together with the same checklist to work together."
Kris Rogness, RN, an operating room staff nurse, says the checklist is an extension of the timeout required by The Joint Commission. Previously, the team paused to check the patient's identification, procedure to be performed, and other basic information before beginning surgery. The new procedure is more than a timeout; it is a timeout with a specific agenda.
"This is a much more detailed checklist with about 20 points that we address, including things such as whether the patient is diabetic, the expected length of surgery, estimated blood loss, whether the patient has blood products ready in the hospital," Rogness says. "It's a much more thorough means of communicating. The previous timeout was very short, and sometimes people totally missed the timeout. This makes us stop and focus."
Howard A Schwid, MD, professor of anesthesiology, says the checklist encourages a greater sense of teamwork. There always has been a lot of talk about being a team, he says, but in reality the surgeon, nurse, and anesthesiologist tended to be in their own world doing their own thing.
"A lot of times, we didn't even know who the other people in the room were. Part of this checklist is that we introduce ourselves to each other before we begin," he says. "It helps to break down the barrier between what goes on one side of the drapes and what goes on the other side."
WHO officials say they hope 2,500 hospitals worldwide will use the checklist by the end of the year. The organization encourages users to adapt the checklist to suit their own conditions and needs. In Washington state, the Surgical Care and Outcomes Assessment Program (SCOAP) a Washington state collaborative of surgeons that involves 42 hospitals and provides data regarding the use of the checklist and other measures with an aim of reducing surgical complications has adapted and added to the WHO checklist to address process issues that arose during initial use of the checklist. Items added to create the WHO/SCOAP checklist include the use of blood thinners to prevent blood clots following operation, the use of insulin to control blood sugar in diabetics, and plans for a second dose of antibiotics for operations that continue for more than three hours.
SCOAP has assembled a coalition of hospitals, professional organizations, health insurance companies, employers, and nonprofit organizations to promote the use of the checklist in every hospital and every operating room in the state of Washington by the end of 2009. Fifteen Washington hospitals have adopted this checklist so far.
To implement the SSSL checklist, Dellinger recommends getting some buy-in from the key leaders in each group involved. He began by discussing the idea within his own department and got key surgeons to endorse the idea, then he went to speak with nurse leaders on each shift about the idea. Then Dellinger spoke on anesthesiology grand rounds to bring them on board.
In each group, there were concerns. One surgeon told him it sounded like a good idea as long as he didn't have to do anything he wasn't already doing. Nurses were worried that they would have to act as the enforcers and make sure the checklist was used. Those concerns were addressed as the plan was implemented, and Dellinger says the past year has been mostly smooth. Some surgeons still only tolerate the checklist, seeing it as unnecessary, but Dellinger says many more have embraced the idea and can see clear benefits.
"A lot of us feel as if we don't know why the checklist hadn't been there all along," he says.
Reference
1. Haynes AB, Weiser MD, Berry WR, et al. A surgical safety checklist to reduce morbidity and mortality in a global population. N Eng J Med 2009; 360:491-499.
With hospitals all over the country realizing that there is a benefit in having the surgical team pause, take a breath, and double-check that everything is in order before proceeding, a hospital in Washington has formalized that process even more by using a checklist that the team can go through before starting the procedure. The simple procedure can have a major impact on patient safety, the hospital reports.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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