Studies show limits of surgical checklists

Are improvements possible?

Checklists are often touted as the potential cure for the ill that is patient harm. If it works for the aerospace industry, why can't it work for healthcare? Indeed, there is ample evidence that some checklists can make a big difference in patient safety.

But two recent studies point out potential limitations — and possible improvements — to checklists designed for making surgical procedures safer.

The first, published in April in the International Journal for Quality in Health Care1 looked at compliance with the WHO surgical safety checklist at a Swedish county hospital. The authors videotaped 24 surgical procedures to see if a time-out really could improve communication, thus reducing medical complications and creating a better safety culture. The procedures were analyzed, and reasons for non-compliance with the checklist and time out ascertained.

The checklist worked best as a tool to ensure the right patient was in the room, the kind of procedure the patient needed was what was scheduled, and that the proper antibiotics were on board. But site of incision and imaging information had the lowest compliance. Team member introductions occurred only half the time, and the time-outs were dominated by the surgeons and anesthesiologists.

The authors noted that the checklist wasn't always used as it was intended, and the very things that are supposed to foster better communication — introductions, for instance — don't always occur. In the small sample, there was a lack of team feeling in the time-outs. One possible solution is to re-educate staff on the relevance of the checklist and why fostering a culture of safety is important.

The second study, also in the April issue of the International Journal for Quality in Health Care2, looked at patient hand-offs and whether checklists work at these high-risk junctures in healthcare. In particular, the researchers looked at whether a checklist for hand-offs between the anesthesiologist and post-anesthesia care unit would lead to better information being available on the patient.

Hand-offs for 120 patients were recorded, with a third of them happening before a checklist was implemented, and the rest happening after. The post-checklist patients were randomized into a checklist group and a group for whom the checklist wasn't used.

The authors looked at the duration of the hand-off, as well as how many specific "items" were part of the hand-off. With the checklist, the number of "items" handed over increased from a median of about a third to nearly 50%, and the length of time for a hand-off increased from about a minute and a half to over two minutes. Even with instructions about what should be handed over, if there was no checklist, there was no associated increase in items handed over.

Given the importance of hand-offs in ensuring quality care and patient safety, using checklists in the post-surgical environment might be helpful.

Reference

1. Rydenfalt C, Johansson G, Odenrick P et al. Compliance with the WHO surgical safety checklist: deviations and possible improvements. Int J Qual Health Care. 2013 Apr;25(2): 182-187.

2. Salzwedel, C Bartz HJ, Kuhnelt I et al. The effect of a checklist on the quality of post-anaesthesia patient handover: a randomized controlled trial. Int J Qual Health Care. 2013 Apr;25(2):176-81.