Simple surgical checklist cuts deaths and complications

Medical Tribune March 2009 P7
David Brill

Using a simple checklist for surgical procedures could dramatically reduce mortality and complication rates across the globe, the “unprecedented” results of a new study show.

Implementation of the WHO-developed list saw post-surgical death rates drop from 1.5 percent to 0.8 percent (P=0.003), and inpatient complications fall from 11 percent to 7 percent (P<0.001)> over 11 months.

The checklist was trialed at hospitals in eight diverse cities, ranging from London to Manila to Ifakara in Tanzania. Data were collected from 3,733 procedures conducted before implementation of the list, and 3,955 after. [N Engl J Med 2009 Jan 29;360(5):491-9]

“The concept of using a brief but comprehensive checklist is surprisingly new to us in surgery. Not everyone on the operating teams was happy to try it,” said Dr. Atul Gawande, senior author of the study. “But the results were unprecedented. And the teams became strong supporters.

“These findings have implications beyond surgery, suggesting that checklists could increase the safety and reliability of care in numerous medical fields. The checklists must be short, extremely simple, and carefully tested in the real world. But in specialties ranging from cardiac care to pediatric care, they could become as essential in daily medicine as the stethoscope,” added Gawande, an associate professor of surgery at Harvard Medical School, US, and team leader for the WHO project.

The checklist was first launched in 2008 as part of new “safe surgery” guidelines from the WHO. It comprises 19 items, and is used at three “critical junctures” in care: before anesthesia, before incision, and before the patient is taken from the operating room.

Rates of surgical site infection also dropped following implementation of the list – from 6.2 to 3.4 percent (P<0.001)> – and unplanned reoperation rates decreased from 2.4 to 1.8 percent (P=0.047).

Dr. Sophia Ang, patient safety officer and associate chairman of the medical board at National University Hospital (NUH), Singapore, said that similar checklists are already in use at NUH.

“Some of these have been in place for a long time, such as an instrument count, sponge count and needle count,” she said.

“There is no deliberate effort on our part to do this as a scientific research so we have no findings to conclusively show that the changes have brought about improved outcomes. Some of the elements were introduced in phases and over time and we are continually reviewing and improving on them to enable us to meet our patient safety needs,” she added.

Some 234 million operations are performed worldwide each year, according to Gawande and his colleagues. At least half of all complications arising from surgery are thought to be avoidable, they add.

The study, which was conducted between October 2007 and September 2008, included only patients aged over 16 who underwent noncardiac surgery. The other cities where the checklist was tested were New Delhi, India; Toronto, Canada; Amman, Jordan; Auckland, New Zealand; and Seattle, US.