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National push under way for surgical safety checklist
Removing reliance on memory
If flight crews have to do it before takeoff, why shouldn't surgical teams do it before cutting into a patient?
Safety checklists aren't about second-guessing anyone's clinical judgment, experts say; they're about making sure, in a systematic way, that the team is ready to proceed, rather than relying on sometimes fallible human memory.
Surgical safety checklists, in particular, have received increasing attention in the last few months, thanks to an important study, a pair of major initiatives, and a memorable scene in a popular television show.
On Jan. 29, The New England Journal of Medicine published "A surgical safety checklist to reduce morbidity and mortality in a global population," spotlighting the favorable outcomes of using a checklist developed by The World Health Organization (WHO). More recently, the TV show ER presented a fictional scenario in which a surgical safety checklist headed off potentially serious problems in a transplant operation. Now the Institute for Healthcare Improvement (IHI) and Washington state-based SCOAP (Surgical Care and Outcome Assessment Program) have implemented programs to get hospitals on board with using a surgical safety checklist, beginning by implementing it in just one OR.
IHI's surgical safety checklist sprint
First announced at its national forum, the IHI's Surgical Checklist Sprint, a voluntary initiative, asks hospitals to implement the use of the checklist in one OR by April 1 "because we advocate doing small tests of change," says Fran Griffin, MPH, IHI director. "When you test something small, then you can learn very quickly whether or not it's going to work as it is or you have to make modifications."
Participating hospitals were asked to report to the IHI if they were going to try to implement it and then follow up as to whether they did. As illustrated in the ER episode, Griffin points to the three areas she sees the most push back to using the tool. First is the perception that "we're doing this already." While she says it might be true that hospitals are doing most of the things on the checklist, the intent is do to all of these things all of the time for all patients.
Three purposes of checklist
Griffin says the purpose of the checklist is not to fill out another form, but is threefold: One is to take three pauses at critical points of a surgery in which the whole team stops and pays attention. The second is that, at a minimum, the team is verbally confirming every element of the checklist. "In fact to meet The Joint Commission's Universal Protocol, they have to go beyond the WHO version, but they're verbally confirming every item."
Third is that "the verbal review is done using some reference that doesn't rely on memory." Moving away from reliance on memory is one of the integral components use of the checklist represents. Staff reluctance to use the checklist, she says, is a misperception of the "process that goes along with the document."
"Another pushback we get, and it's not so much push back as much as people being concerned, legitimately so, about the fact that this will not meet the Universal Protocol," Griffin adds. The Universal Protocol, she says, was intended primarily to avoid wrong-site or wrong surgery. The checklist, however, was not designed with this in mind but rather to provide safer surgical care. Griffin insists that the two can be used as complements to one another, especially as the IHI promotes modifying or adapting the checklist to include what elements you want.
The third most common pushback, Griffin says, which they expected to encounter more often then they have, is from physicians. She says often older surgeons are the ones who are most resistant and who might have been trained to think differently about the OR. "They view this as people second-guessing their ability, their judgment, their intellect, and of course we all know that's not the goal here at all."
Griffin and other experts say they don't favor legislation or regulation regarding the list. Rather than being mandated, Griffin hopes it just becomes a standard of care. And unlike the Universal Protocol, which focuses on wrong-site and wrong surgery, which she says is a very rare occurrence, use of the checklist "is not so punitive and blameful to a lot of surgeons."
While she already has seen documents from one state considering mandating the checklist, Griffin says "legislation can sometimes have unintended consequences." The beauty of the Sprint, she says, is that there aren't set-in-stone actions. The intent is to take the three pauses and fulfill what the checklist is designed for. She says the fact that it is a checklist with boxes often gives the wrong perception: that users are supposed to check off the boxes. It's not about checking boxes, but asking the questions and taking the time to note that everything is done or made ready.
"Sometimes people shoot themselves in the foot in making these things more complex than they need to be," Griffin says, "and my worry would be that if you legislated this, it would come out as too prescriptive."
The checklist represents a lot of the characteristics integral to a high-reliability organization (HRO), which is a concept Griffin often speaks about, such as preoccupation with failure. "When we go into the OR, the assumption is that everything is going to go well," she says, but "it's about being ready, recognizing that no matter how good anybody is that nobody is 100% all of the time, humans are fallible, and the policies and processes we're using were designed by humans. So, failure is a given."
The checklist, Griffin says, addresses possible failures "that if they occur are going to put us in the greatest risk of harm to the patient. Failure to give the antibiotic is one. Failure to have the blood in the OR and ready if we need it is another."
Another HRO component, deference to expertise, also is highlighted by the checklist. Griffin asks: Who is the best person in the room to answer questions about the airway? The anesthesiologist, she says. "But prior to the WHO checklist, were people pausing to ask the anesthesiologist: Do you think the airway is easy or difficult today? That information was known to the anesthesiologist, but not the rest of the team," Griffin points out. Deference to expertise means you're going to the one on the team who best knows that answer, such as going to the scrub nurse to ask if the team has everything it needs. Questions include: Did we check the equipment? Did we give the antibiotic?
Griffin points again to eliminating the variability that comes from reliance on memory as one of the key benefits of using the checklist.
SCOAP scopes out checklist
SCOAP is a nonprofit, voluntary, physician-led collaborative to improve the quality of surgical care. Among its programs is one promoting use of a surgical checklist. Its goal is to have every hospital using it in every OR in the state by the end of the year. At press time, there were 42 hospitals signed on with the checklist initiative.
Rosa Johnson, ARNP, MN, CPHQ, SCOAP program director, says use of the surgical checklist is "very logical, very practical." The checklist differs a bit from the World Health Organization (WHO) checklist and includes "a number of process-of-care measures. Like being sure that the patient whose blood glucose is high gets treated and beta-blockers are continued." Step Two of the checklist, intended to be checked prior to skin incision, includes elements such as: active warming in place, deep vein thrombosis/pulmonary embolism prevention plan in place, antibiotic re-dosing plan in place, specialty-specific checklist needed, and agreed-upon plan to prevent sharps injury. For these elements, hospitals are asked to track whether each has been confirmed as part of the checklist. (Editor's note: To view the checklist, visit www.scoap.org.)
Costco printed poster-sized checklists at no cost to SCOAP that facilities can order. The posters are 2x3 feet and are laminated so hospitals can hang them in ORs and can use them over and over. Another suggestion Johnson makes for implementing the checklist is putting it in the basic sterile pack. Other suggestions are listed on the web site, but Johnson says SCOAP has not been prescriptive on how hospitals use the checklist.
"We basically tell them, like you do anything where you're going to have something really happen, you need to develop a team and you need to have your leaders or champions." SCOAP offers a pre- and post-implementation survey hospitals can use to gauge perceptions on how the checklist has changed safety in the ORs. And she points to one of the greatest benefits of the checklist approach.
"I think it's a very practical way to improve care in the OR and represents the recognition that we are people and we are human and we can't remember everything," Johnson says. Surgical care is complex, she adds. "Just like pilots who can't remember everything, so they have a checklist to remember," Johnson says. "I think it's an acknowledgement that surgeons and staff can't remember everything, and we need a checklist to help us remember."