Simple checklist markedly reduces surgical deaths-updated video
Using a simple checklist to make sure operating teams completed important safety tasks before, during and after operating, reduced surgical deaths and serious post-operative complications by roughly one third, according to a study done in eight hospitals around the world, including the University of Washington in Seattle.
Updated Video
The study was conducted by the Safe Surgery Saves Lives Study Group, which is sponsored by the World Health Organization. The University of Washington was the only U.S. facility participating in study.
The paper appears in this week’s issue of the New England Journal of Medicine.
“It’s unequivocally clear that using the checklists has taken the teamwork and communication to a new level in the operating room,” said Dr. Patchen Dellinger, professor and vice chair in the Division of General Surgery at the University of Washington Medical Center, who led the UW arm of the study.
Often people working on teams are reluctant to speak up about problems, Dr. Dellinger said, but under this system “everyone is allowed, encouraged to tell the surgeon or the chief anesthesiologist that they’re doing something stupid or forgetting something,” he said.
“It gives the everyone the feeling that ‘we’re in this together’,” he said.
The other hospitals that participated in the study were in Toronto, Canada; New Delhi, India; Amman, Jordan; London, England; Auckland, New Zealand; Manila, Philippines; and Ifakara, Tanzania.
The study compared the rates of surgical deaths and post-operative complications among 3733 patients who underwent non-cardiac surgery before the checklists were introduced with the rates of death and complications among 3955 patients who underwent non-cardiac surgery after the checklists were adopted.
When the checklists were adopted, the surgical team was required to go through the checklists are three key points of the operation, called “Sign In”, “Time Out”, and “Sign Out”.
This requirement gave the team a moment to stop and make sure everything was being done correctly. Such practices have been shown in other studies to enhance teamwork and improve outcomes.
” Sign In”, for example, begins before the patient is given anesthesia. At that time, members of the team (at least a nurse and an anesthesia professional) orally confirm that the patients has verified who he or she is and the surgical site, and has given consent.
The site is then marked (to prevent operations being performed on the wrong leg, for example).
At this time, all members of the team also made aware if the patients has a known drug allergy, since drug reactions due to allergies is common cause of problems.
The team also evaluates the patient’s airway and risk of blood loss and takes the necessary steps at that time to deal with any potential problems.
“Time Out” is performed before the incision is made. At this time, the members of the team orally introduce themselves and roles. The patient’s identity, surgical site, and procedure is then confirmed, and the team reviews the operation, potential problems, and makes sure of such things as whether necessary pre-operative antibiotics have been given and whether all supplies and necessary equipment are present.
“Sign Out” includes such steps as making sure all the needles, sponges and instruments are accounted for to make sure nothing has been inadvertently left in the patient, a common surgical mishap.
Overall, after introduction of the checklists, surgical deaths and postoperative complications rates fell by about one-third.
Specifically, for all eight hospitals the rate of death was 1.5 percent before the checklists were introduced and fell to 0.8 percent afterward, while the rate of postoperative complications fell from 11.0 percent to 7.0%.
Hospitals in low-income sites saw their surgical death rates drop by half, from 2.1 percent to 1.0 percent and their complication rates fall from 11.7 percent to 6.8 percent.
Hospitals in high-income sites saw their complications rate fall from 10.3 percent to 7.1 percent. Surgical death rates at high-income sites fell as wll, from 0.9 percent to 0.6 percent, but this decline was not statistically significant.
Since November all surgical teams at UW have adopted the checklist. WHO hopes to have the checklists adopted by 2,500 hospitals worldwide by the end of 2009.
In Washington state, more than 40 hospitals have now joined a project called the Surgical Care and Outcomes Assessment Program, which includes the adoption of the of checklists and other quality improvement initiatives.
To learn more:
- Read the article in the New England Journal of Medicine (fee or subscriptions may be required).
- The Web site of Surgical Care and Outcomes Assessment Program, a collaborative effort by surgeons at 42 Washington state hospitals to use checklists and other measures to reduce surgical complications.
- View a longer Checklist Training Video produced by the University of Washington
Category: Hospital News, Surgery, University of Washington
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