Simple Checklist Makes Surgery Safer

By ERIC NAGOURNEY

16 jan 2009--A checklist for surgical teams that includes steps as basic as having the doctors and nurses introduce themselves can significantly lower the number of deaths and complications, researchers reported Wednesday.

“Surgical complications are a considerable cause of death and disability around the world,” the researchers wrote in the online edition of The New England Journal of Medicine. “They are devastating to patients, costly to health care systems and often preventable.”

But a year after surgical teams at eight hospitals adopted a 19-item checklist, the average patient death rate fell more than 40 percent and the rate of complications fell by about a third, the researchers reported.

The senior author of the study, Dr. Atul A. Gawande of the Harvard School of Public Health, said it was hard to identify which items on the checklist had proved the most important.

But even a small change, like having surgical team members take a moment to say who they are and what they do before scalpel touches skin, can have important consequences later on should one of them develop a concern during the operation. Earlier studies have shown that communication problems are fairly common in operating rooms, with junior members of the team sometimes hesitant to speak up.

“Giving them a chance to say their names allows them to speak up later,” Dr. Gawande said.

Other items on the checklist are of more obvious importance, like a requirement that the nursing staff confirm that everything has been sterilized and that all equipment needed is present. Team members must also confirm that the patient has been given antibiotics ahead of the surgery, if called for, to reduce the chance of infection.

The checklist also requires team members to verify that there is enough blood on hand if there is a risk of blood loss, that a piece of equipment that measures blood oxygenation is working and that all the medical images needed are present.

Before the operation begins, the checklist calls for the team to confirm the identity of the patient and the nature of the procedure. Afterward, the doctors and nurses are supposed to review what has been done, including discussing any special steps that need to be taken to aid recovery and confirming no equipment has been left in the patient.

The researchers, working with the World Health Organization, conducted the study over a year at hospitals in the United States, Canada, England, Jordan, New Zealand, India, the Philippines and Tanzania. The lead author of the study was Dr. Alex B. Haynes of Harvard.

The researchers reviewed the outcome of 7,688 patients who were undergoing noncardiac surgery at the hospitals. About half the patients had surgery before the checklists were adopted, and half after. At the end of the study, the average death rate dropped to 0.8 percent from 1.5 percent, and the average complication rate fell to 7 percent from 11 percent.

Some of the hospitals in the study have already begun using the checklist regularly, the researchers said. The changes can be made quickly and at little cost, they said.

The improvements in outcome, the researchers said, most likely came about not because of any one or two items on the checklist but from a combination of factors. Beyond that, the changes in procedure may have brought about a broader change in behavior that improved safety. The fact that the surgical teams knew that they were being studied may also have kept them on their toes, the researchers said.