Surgical Checklists: Improving Patient Safety and Outcomes

Checklists have their origins in aviation—planes are complex vehicles with a host of features that need to be checked before flight. Checklists offer pilots an easy, standardized system that ensures safety and thoroughness. Similarly, surgery is a complex system with many moving parts. Over the past two decades, health organizations and hospitals have developed surgical checklists as part of their protocols. Today, the World Health Organization recommends that checklists be included as a standard part of every surgical procedure.[1] 

Medical errors cause up to 100,000 deaths every year in the U.S., according to the Institute of Medicine. Unfortunately, many of these deaths are due to a lack of error management precautions.[2] However, the implementation of appropriate precautions through checklists have been shown to have a markedly positive effect on patient health. A study by Pronovost et al. found that mortality rates for patients in intensive care declined by 3.1% after a checklist was implemented. Patients also spent less time in the ICU and fewer days on the ventilator.[3] 

Studies have also demonstrated that checklists are particularly effective in ensuring positive patient outcomes in high-intensity medical fields like anesthesiology. A study by Hart et al. used an electronic checklist device, like the ones used by pilots, in anesthesia trials. An overwhelming majority— 95%—of participating anesthesiologists reported finding the electronic checklist useful in their procedure. 

In these high-intensity environments, information exchange during the preoperative process is of utmost importance. A study by Tscholl et al. found that 88% of anesthesia teams using an anesthesia pre-induction checklist displayed better knowledge of critical information and increased information exchange. They also managed to complete all of the procedures without a single medical error. The control group, which did not use a surgical checklist, experienced two critical errors.[4]  

A smooth postoperative process is essential to positive patient outcomes. However, studies have shown that the handoff process is particularly prone to miscommunication or other errors. A study by Dai and Robbins found that just 14% of postoperative handoffs were considered acceptable.[5] This was because members of the operating team frequently forgot to relay information about patients to the postoperative team. However, after the implementation of surgical checklists, 100% of postoperative handoffs in the study were deemed adequate. 

There is a direct connection between patients’ postoperative outcomes and the use of a checklist. A global study by Haynes et al. found that, on average, the use of checklists led to a 36% drop in postoperative complications.[6] Postoperative mortality rates fell by a similar amount. Indeed, over the past decade, an array of literature has demonstrated that checklists are effective in improving patient safety during procedures and their outcomes after the operation. 

References 

[1] Borchard A, Schwappach DL, Barbir A, Bezzola P. “A systematic review of the effectiveness, compliance, and critical factors for implementation of safety checklists in surgery.” Annals of Surgery. vol. 256, no. 6, 2012, pp. 925–33. doi: 10.1097/SLA.0b013e3182682f27. 

[2] Hales, Brigette M., and Peter J. Pronovost. “The Checklist—a Tool for Error Management and Performance Improvement.” Journal of Critical Care, vol. 21, no. 3, Elsevier BV, Sept. 2006, pp. 231–235. doi:10.1016/j.jcrc.2006.06.002. 

[3] Pronovost, Peter, et al. “Improving Communication in the ICU Using Daily Goals.” Journal of Critical Care, vol. 18, no. 2, Elsevier BV, June 2003, pp. 71–75. doi:10.1053/jcrc.2003.50008. 

[4] Tscholl, David W., et al. “An Anesthesia Preinduction Checklist to Improve Information Exchange, Knowledge of Critical Information, Perception of Safety, and Possibly Perception of Teamwork in Anesthesia Teams.” Anesthesia & Analgesia, vol. 121, no. 4, 2015, pp. 948–956., doi:10.1213/ane.0000000000000671. 

[5] Robins, Holly-May, and Feng Dai. “Handoffs in the Postoperative Anesthesia Care Unit: Use of a Checklist for Transfer of Care.” AANA Journal, vol. 83, no. 4, Aug. 2015, pp. 264–268. PMID: 26390744. 

[6] Haynes, Alex B., et al. “A Surgical Safety Checklist to Reduce Morbidity and Mortality in a Global Population.” New England Journal of Medicine, vol. 360, no. 5, 2009, pp. 491–499., doi:10.1056/nejmsa0810119.