The next big break through in surgery might not be a sophisticated new tool or imaging device; instead, it may be a simple checklist that the surgical team has to run through before making the first incision. In a pilot study, researchers found that using the checklist cut the death rate following surgery by 47 percent, while the complication rate decreased by 36 percent. The procedure is simple: Surgeons and nurses run through a series of basic safety checks before each operation, similar to those made by pilots before take-off. The checks include asking: Is this the right patient? Is this the right limb? Has the patient had the right drugs? [The Independent]
The checklist is composed of 19 fairly obvious items, but lead researcher Atul Gawande says that 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 [The New York Times].
The pilot study was an initiative of the World Health Organization. The research team tested their simple idea with often dubious and unhappy surgical teams operating on more than 7,500 surgical patients in eight hospitals in Toronto, Seattle, London, New Delhi, Amman, Auckland, Manila and Ifakara in Tanzania [Reuters]. Interestingly, the hospitals in both developed and developing world countries saw about the same reduction in post-surgical complications. Based on the checklist’s unambiguous benefits, which were reported in the New England Journal of Medicine, Britain’s health agency announced that all surgeons in England and Wales must start using the checklist by February 2010.
Some surgeons may resist integrating the checklist into their routine, says Peter Walsh, of the medical watchdog group Action against Medical Accidents. “Some surgeons say that checklists de-professionalise them, turning them into automatons who don’t think” [The Independent], he says. Other surgeons argue that they already ask all the questions listed on the checklist, and don’t need a piece of paper to remind them how to do their jobs. But the research team maintains that the checklist ensures consistency in surgical procedures, and also promotes teamwork and communication. Those simple factors can save a lot of lives and prevent a lot of pain, says Donald Berwick, the president of the US Institute for Healthcare Improvement. “I cannot recall a clinical care innovation in the past 30 years that has shown results of the magnitude demonstrated by the surgical checklist” [The Independent], he says.
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Image: iStockphoto
January 15th, 2009 at 10:53 am
The checklist is composed of 19 fairly obvious items, but lead researcher Atul Gawande says that 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.
January 15th, 2009 at 1:22 pm
“Some surgeons say that checklists de-professionalise them, turning them into automatons who don’t think”…
Do you think these same surgeons would feel more comfortable flying on a plane in which the airlines/regulatory agencies do not require the pilots to use pre-flight checklists?
Process-based activities benefit greatly from checklists. Any surgeon who doesn’t see that should get an eg0ectomy.
January 15th, 2009 at 1:25 pm
Check lists are used before any important matter Space flight, leaving for the office and now surgery.
I would have thought that would have been one of the first things to do as I think that it is important to cut off the correct leg and other smaller things even the question “is the patient facing the right way”.
At last some one with common sense which I have been informed is not that common.
January 15th, 2009 at 2:16 pm
You’d think that they would already have pre-surgery checklists in most hospitals. Now I could see if the checklists differed from one hospital to the next but to not have one at all? I just had ACL reconstruction last week and was asked 3 times by different people which leg it was and it was marked as well before the surgery. I would have to agree with Damien on this one… I doubt that surgeons feel that this would “de-professionalise” them, more than likely it’s probably their ego getting in the way.
January 15th, 2009 at 2:17 pm
Sorry, I meant Dustin.
January 15th, 2009 at 5:31 pm
I was at Baylor Hamilton Heart & Vascular Hospital a couple of weeks ago for an EP study and ablation procedure. As soon as I entered the operating room I was introduced to everyone and questioned thoroughly about everything; my name birth date, why I was there(the form was not correct so they updated it and I initialed it), etc. etc. I don’t know if there were nineteen steps but it seemed like almost that many. During the procedure communications between all the personnel was clear, crisp and very professional. I was impressed.
January 16th, 2009 at 7:37 am
Good thing you went to Baylor instead of Johns Hopkins Cardiology. Read what could have happened to you during a catheter ablation procedure at “America’s Best Hospital”: http://adventuresincardiology.com
or Google “Adventures in Cardiology”
January 16th, 2009 at 12:41 pm
A similar “ego” problem was solved in the airline industry. Surgeons and Pilots have similar psychological profiles. Aggressive, assured, self confident, use of intimidation against peers etc. FAA and the airline industry found in investigating airline accidents, that lack of cockpit cooperation, lack of anticipation of what to do next, …the other pilot was supposed to do something….was a heavy contributor to accidents. So a protocol was born called Cockpit Resource Management defining how the pilots work together and in which ways.
This CRM protocol is now standard among most airlines in the world
January 20th, 2009 at 7:48 am
Sounds like cookbook medicine. I can see how using a checklist can make one feel that the procedure is automated and that you are simply a part in the machine. However, I have been in these settings and I can say that communication can be surprisingly poor. It is especially galling when I ask for a medicine to be administered and there is no feedback that it has been given so I am not sure where I am at with the total dose given to the patient. After having to ask for the 10th time whether or not the drug has been given I sometimes get frustrated enough to stop asking for confirmation. Speaking to the person afterwards usually doesnt stop the behavior for the next procedure. Making the feedback process part of hospital protocl would solve that kind of problem. Since two or more heads are better than one I can see the value of breaking potentially intimidating authoritarian air that ices the OR and allowing others to speak up when they think they see something amiss. I have found that more than half of the time when somebody speaks up they are right. Some potentially embarassing mistakes have been prevented by such observations. So even though such procedures may be seen as silly and limiting like using a cookbook, there is a reason why people still use recipes since following them prevents mistakes from being made and steps from being missed. The next time you fly in a plane you can be thankful that the pilots who opposed checklists were silenced and the phenomenal improvement in flying safety that has been the result.