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Study: Safety checklist reduces mortality
International study supports use of WHO guidelines
According to a recent study in the New England Journal of Medicine, "data suggest that at least half of all surgical complications are avoidable."1 The article goes on to say that teamwork in surgeries has been shown to lead to improved outcomes.
In the international study, led by Alex B. Haynes, MD, MPH, researcher at Harvard School of Public Health and a surgeon at the Massachusetts General Hospital, a 19-item surgical safety checklist created from the World Health Organization's guidelines for surgical safety was used at eight hospitals in eight cities to access the effect on the rate of complications, including mortality, during hospitalization within 30 days post-procedure (non-cardiac surgery). (To see checklist, visit www.safesurg.org.)
Before introduction of the checklist, the rate of death was 1.5%; that rate declined to 0.8% with use of the checklist. Inpatient complications at baseline occurred in 11% of patients; after the checklist was introduced, that number fell to 7.0%. The study used six safety measures to indicate process adherence.
Does use of the checklist represent a simple fix to hospitals still struggling to comply with The Joint Commission time-out before surgery goal? The checklist "is very simple on a very superficial level," Haynes tells Hospital Peer Review. "What's underneath is a very complex change in the way care is organized in the operating room, in the way teams behave."
What's key about the checklist, he says, is that it's not just a piece of paper in a pile on some corner desk, "but rather that it's an active document that requires active participation and verbal participation from all team members."
Another challenge to implementing such a system, he says, is that OR personnel have myriad documentation tasks and "there is a misperception by many people that the checklist is simply a documentation tool, which is not at all the intent of it."
Many sites, which were encouraged to modify the checklist to their needs and population, didn't include check boxes at all. Often the exercise, he says, was done verbally. No sites kept the checklist as a tangible document; some kept compliance questionnaires in which they would mark whether the checklist was used.
Providers can "get lulled into complacency" with written documentation, Hayes says. "Evidence in aviation has shown the difference between a verbal checklist and a written checklist is about a tenfold improvement in intertrapping. Verbal performance, in order of magnitude, is more effective at catching errors than a written checklist," he says.
Each study site had a local co-investigator who was in an esteemed position at the hospital. Because of their participation, Hayes says, they were able to convince administration of the importance of the study and the checklist.
Changes in processes related to the study included giving antibiotics in the OR rather than peri-operative suites and confirming patients in the OR by OR personnel. "A lot of the sites relied on a patient confirmation that took place in the pre-op holding room rather than in the operating room or by the team who was actually going to be caring for the patient in the operating room," Hayes says. "That just allows one more possibility for errors to occur."
Hayes does not recommend regulating use of checklists like this one. "The kind of behavior changes that are a part of it are not things you can impose upon people," he says. "You need to get people educated and to accept them on their own."
He points again to the aviation industry. "Even in the airlines, where checklists have been ubiquitous for decades, the FAA doesn't mandate these specific checklists or specific sets of steps for airlines — just simply that they use safety measures, that's the only mandate."
He suggests that facilities implementing this checklist approach not put "everything under the sun" in it. "We would suggest anyone who is modifying it do it in a thoughtful fashion... You can't solve every problem in health care by putting it on the checklist."
He suggests sites use it as part of a quality improvement endeavor they already track data on and to collect information early to identify where the checklist isn't being used.
"I think a key to making this work at an institution is to obtain buy in from both the top and the bottom. This really needs to be clinician-led. You need to have a champion in the OR," he says. Use it in one OR and test it again in that setting before rolling it out to others. And he suggests obtaining feedback from personnel using it and providing that feedback to physicians.