Training and checklist cut postop complications

Training sessions focus on communications

Two simple cost-effective methods — communications team training and a surgical checklist — have been shown in a study to reduce postoperative complications,1 which are the most expensive medical errors, averaging $14,500 per case.2

Investigators have found that when surgical teams completed communications training and used a surgical procedure checklist before, during, and after high-risk operations, patients experienced fewer adverse events such as infections and blood clots. The study was conducted at the University of Connecticut Health Center, Farmington, and Saint Francis Hospital and Medical Center, Hartford, CT.

While this study builds on previous research about the benefits of using checklists, it is the first to look at how communications training can help surgical teams have productive conversations around patient care while using the checklist, explained Lindsay Bliss, MD, lead study author and general surgery resident at the University of Connecticut.

The drop in postoperative complications has implications for national healthcare spending because Medicare and other health insurance providers are starting to decline reimbursement for complications that result from the clinicians' errors, especially just a month after the patient's procedure.

"Every adverse outcome results in more expense," Bliss said. "It means a longer stay in the hospital and more treatment. Communicating and using a checklist do not just add extra minutes on to the procedure. There is an ethical and financial obligation tied to both tools."

Occasionally unforeseen circumstances can occur during surgery. Sometimes surgical equipment isn't on hand, or the patient requires more blood than expected, which delays the procedure and requires dispensing more anesthesia while a team member hurries to obtain needed supplies. Also, surgical team members might have inconsistent information about priorities for the procedure, Bliss said.

"Everyone brings to the team a different aspect of patient care that they think is the most important," she said. "But the team has to understand all aspects of patient care and agree on what's important."

For the study, Bliss' colleagues compared three groups of surgical procedures to determine whether communications training coupled with a standardized checklist could bring surgical teams into agreement and reduce patients' complications. The communications training included three sessions on topics such as differences between introverts and extroverts, effective dialogue among all operating room personnel, and how to use a surgical checklist.

The communication training was given by internal professional development staff at Saint Francis. The curriculum was primarily developed internally by one of the trainers as well as members of the research team. Key principles were from the text "Crucial Conversations: Tools for Talking when Stakes are High" (McGraw Hill).3

Although surgical checklists have existed for a while, they are not universally used. Bliss' team used the one-page Association of periOperative Registered Nurses (AORN) Comprehensive Surgical Checklist developed in April 2010. (The checklist can be accessed at It includes protocols mandated by the World Health Organization (WHO), The Joint Commission, and the Centers for Medicare and Medicaid Services (CMS), and it has been endorsed by the American College of Surgeons (ACS) and other surgical organizations.

For one group of procedures, the surgical team selected operations from the ACS National Surgical Quality Improvement Program (ACS NSQIP) database. These operations occurred between January 2007 and June 2010 and served as the baseline group, because these surgical teams had not gone through the communications training or used a checklist. Bliss said pulling this information from the ACS NSQIP database allowed the researchers to access standardized clinical and demographic data on the patients, along with information about 30-day surgical outcomes.

These procedures were compared with two other groups of surgical procedures that occurred between December 2010 and March 2011. In one group, 246 procedures involved surgical teams who had undergone communications training, while the other group included 73 procedures involving surgical teams who had not only gone through the same communications training, but also used the checklist.

Study results showed that the communications training coupled with the checklist curbed complications within 30 days of the procedures. Complications included surgical site infections (SSIs), vein blood clots, lung blood clots, and urinary tract infections (UTIs). When surgical teams had no communications training and did not use checklist, more than 23% of the procedures resulted in complications within 30 days. About 16% of procedures by surgical teams who only participated in communications training led to complications within 30 days, and only 8.2% of the procedures had a 30-day complication when the surgical teams used the communications training and the checklist.

Even small steps such as making sure everyone on the team introduced themselves before the procedure helped reduce complications. Bliss said. "The theory is that this brings a sense of accountability and makes sure that everyone's voice can be heard," she explained. "No one on the surgical team is a nameless, faceless body. The checklist makes sure everyone is advocating for the patient."

She pointed out that the checklist is free and available online. "The cost of a photocopy in exchange for reducing patient morbidity is a fabulous return on investment," Bliss said.


  1. Bliss LA, Ross-Richardson CB, Sanzari LJ, et al. J Amer College Surgeons 2012; 215(6): 766-776.
  2. Shreve J, van Den Bos J, Gray T, et al. The Economic Measurement of Medical Errors. Schaumburg, IL: Society of Actuaries and Milliman; 2010.
  3. Patterson K, Grenny J, McMillan R, et al. Crucial Conversations Tools for Talking When Stakes Are High. 2012; McGraw Hill: Columbus, OH.