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Surgical Checklist and Patient Safety: More Than Just Checking a Box

Summary and Comment |
April 18, 2014

Surgical Checklist and Patient Safety: More Than Just Checking a Box

  1. Neil H. Winawer, MD, SFHM

Implementing surgical safety checklists in Ontario, Canada, failed to prevent perioperative mortality or complications.

  1. Neil H. Winawer, MD, SFHM

In 2009, the World Health Organization (WHO) introduced a 19-point surgical safety checklist that significantly lowered the rate of inpatient complications and mortality for patients who underwent noncardiac surgery (NEJM JW Gen Med Feb 3 2009). Despite the checklist's widespread adoption, the effect of mandatory implementation on surgical safety is unclear.

Using administrative data, researchers compared the effects of a surgical checklist at 101 hospitals in Ontario, Canada. After studying 3-month periods before and after implementation of the checklist (>100,000 procedures performed in each period), researchers found no differences in risk-adjusted mortality during hospitalization or within 30 days after surgery (pre-checklist, 0.71%; post-checklist, 0.65%). No differences were seen in risk-adjusted complications or 30-day readmissions. Additionally, the checklist did not prevent operative mortality in any subgroup, including patients who underwent higher-risk procedures, such as emergency or inpatient procedures.

Comment

During the study, participating hospitals self-reported high adherence to the checklist (range, 92%–100%). So what went wrong? Although checking off boxes on a list of patient safety practices is easy, the actual implementation of specific items on the checklist (e.g., facilitating a teamwork approach) is challenging. As an editorialist notes, the checklist is simply a tool to ensure that team communication happens, and it only works as intended if it's used properly. Finally, data suggest that checklists are most effective if they are used throughout the entire perioperative period (NEJM JW Hosp Med Jan 24 2011) and that they improve patient safety over time, as they become fully implemented. Three months probably wasn't enough time after adoption of the checklist to measure such benefit.

  • Disclosures for Neil H. Winawer, MD, SFHM at time of publication Editorial boards ACP Hospitalist

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