◊ BACKGROUND:
Surgery has become an integral part of global health care, with an estimated 234 million operations performed yearly. Surgical complications are common and often preventable. We hypothesized that a program to implement a 19-item surgical safety checklist designed to improve team communication and consistency of care would reduce complications and deaths associated with surgery.
◊ METHODS:
Between October 2007 and September 2008, eight hospitals in eight cities (Toronto, Canada; New Delhi, India; Amman, Jordan; Auckland, New Zealand; Manila, Philippines; Ifakara, Tanzania; London, England; and Seattle, WA) representing a variety of economic circumstances and diverse populations of patients participated in the World Health Organization's Safe Surgery Saves Lives program. We prospectively collected data on clinical processes and outcomes from 3733 consecutively enrolled patients 16 years of age or older who were undergoing noncardiac surgery. We subsequently collected data on 3955 consecutively enrolled patients after the introduction of the Surgical Safety Checklist. The primary end point was the rate of complications, including death, during hospitalization within the first 30 days after the operation.
◊ RESULTS:
The rate of death was 1.5% before the checklist was introduced and declined to 0.8% afterward (P=0.003). Inpatient complications occurred in 11.0% of patients at baseline and in 7.0% after introduction of the checklist (P<0.001).
◊ CONCLUSIONS:
Implementation of the checklist was associated with concomitant reductions in the rates of death and complications among patients at least 16 years of age who were undergoing noncardiac surgery in a diverse group of hospitals.
◊ Reviewed by R. Stienstra, M.D., Ph.D,
Nijmegen, Netherlands
There is a growing body of evidence that the introduction of checklists and time-out procedures in the perioperative process helps in the prevention of errors and complications, and this study adds to that evidence.
The checklist used in this study contained 19 items. Some of them speak for themselves, whereas the added value of others is not so evident. For example, that verifying the patient’s identity, the planned surgery, and the operative site will diminish the incidence of operating the wrong patient or prevent left-right confusions is obvious. But reviewing aloud key concerns for the recovery and care of the patient before he/she is signed out from the OR by surgeon, nurse and anesthesia professional seems to me like a bureaucratic ritual of accumulating clichés, which is not likely to improve patient outcome.
The major finding of this study, i.e. that using the checklist reduces both mortality and complications, is important. However, the design of the study does not allow any conclusions about the relative contribution of individual items to the improvement in outcome.
Strategies such as the use of a checklist with the aim of reducing errors and complications in the perioperative process are a welcome improvement to standard care. The key to success of implementing such strategies lies in that all parties involved are conscious of the role of each step in the procedure. Therefore, a successful checklist should just contain items that are either self-evident or evidence-based.
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