Published in: Boston Globe
Issue/Volume: January 15, 2009
Written by: Liz Kowalczyk

1/15/2009 – The eight hospitals that participated in the international study collectively reduced complications during hospital stays from 11 percent of patients before they began using the checklist to 7 percent of patients when using the checklist. Deaths dropped from 1.5 percent of patients to 0.8 percent.

“It was beyond anything we expected,” said Dr. Atul Gawande, senior author of the Harvard School of Public Health paper and a surgeon at Brigham and Women’s Hospital. The impact of all the items on the checklist “put together seems to have produced these really remarkable results,” he said.

Gawande, an advocate of the surgical checklist who began using it in his own operations a year ago, said he hopes that the results will help win over surgeons and other operating room staff who are skeptical about the usefulness of checklists and believe they waste precious minutes when pressure to turn over operating rooms quickly is greater than ever.

While the study was published online by the New England Journal of Medicine yesterday, the Brigham and some other US hospitals had already implemented the 19-step checklist in their operating rooms, based on early word about the strength of the data. The Brigham, which was not part of the study, began using the checklist a month ago in general and cardiac surgery and plans to roll it out to other specialties over the next several months, Gawande said.

The checklist is based on World Health Organization guidelines and takes only a couple of minutes to complete. It requires operating room staff to complete a series of verbal steps before giving the patient anesthesia, before the incision, and before the patient leaves the operating room. These steps include verifying out loud that an anesthesia safety check was completed and that surgeons are about to perform the correct procedure; confirming that all team members have introduced themselves by name to one another and discussed any concerns; and verifying that all sponges and needles are accounted for after surgery, and that none has been left inside the patient.

Completing the checklist out loud as a team is crucial to uncovering lapses that lead to problems, said Dr. Alex Haynes of the Harvard School of Public Health, the lead author and a surgeon at Massachusetts General Hospital.

“Saying it verbally codifies things more than simply having one person check a box,” Haynes said. It requires more attention, he said, and a greater sense of collective responsibility.

Gawande said that in his own operations, the checklist catches a potential problem about once a week. In one instance, he told the team before beginning surgery that his patient’s adrenal tumor was stuck to a major vein. As a result, the anesthesiologist brought more blood into the room to prepare for the possibility of major blood loss, one of the items on the checklist.

“The patient lost huge amounts of blood in under a minute,” Gawande said. “He was saved by the fact that the anesthesiologist had the blood right there.”

The hospitals that participated in the study vary in size, income level of patients, and location – Jordan, India, Tanzania, Philippines, Canada, England, New Zealand, and the United States – but they all reduced their complication rates with the checklist, which does not require a large financial investment. The study results mean that 158 of 3,955 surgery patients whose cases included the checklist potentially avoided complications such as an infection, reoperation, or death.

Use of the checklist will not completely eliminate complications, the authors said, because some are caused by the patient’s underlying disease or by a more complicated set of factors. The checklist, for example, did not reduce the incidence of pneumonia.

Many doctors and nurses, however, warn that implementing safety checklists in operating rooms is not as simple as it sounds. Even a shorter “time out” used by most US hospitals to help prevent operating on the wrong patient or the wrong side of the patient or doing the wrong procedure, has not been foolproof. Implementation is sometimes spotty, partly because a procedure can become so routine that staff members just go through the motions without really checking each item.

The Joint Commission, a national organization that accredits hospitals, adopted a requirement in 2004 that hospitals perform “time outs” to prevent these types of errors, but soon discovered that mistakes were still occurring. It has revised the procedures.

Certain surgeons may refuse to do time outs, or a surgeon can become distracted on a particularly hectic day.

While most hospitals do some of the 19 steps on the checklist used in the study, some operating room staff members worry that implementing an entire 19-part checklist will take too much time, especially at the end of a case, which is particularly hectic as staff try to ready the patient for the recovery room.

“They’re going to be talking about delaying surgical starts,” said Stephanie Stevens, an operating room nurse at Jordan Hospital in Plymouth for 21 years.

The authors said it takes a strong commitment by hospital leadership to adopt this type of change.

Some professional organizations, patient safety groups, and hospitals are already embracing the checklist. Ten hospitals in the state of Washington are implementing the checklist. And the Institute for Healthcare Improvement, a patient safety organization that is based in Cambridge, is asking 4,000 hospitals to implement the checklist in at least one operating room in the next three months. The Massachusetts Hospital Association said it will encourage that effort in this state.

Haynes said patients should consider whether a hospital uses the checklist or a similar one before deciding to have surgery. “I encourage patients to bring it up with their doctors, to show they are interested in this type of change,” he said.