Published 21 January 2009, doi:10.1136/bmj.b220
Cite this as: BMJ 2009;338:b220

Editorials

Surgical safety checklists

Improve collaborative teamwork, minimise surprises, and reduce harm to patients

Surgical deaths and complications are a global public health problem. The World Health Organization estimates that each year half a million deaths related to surgery could be prevented.^{1 2} In England and Wales, the National Patient Safety Agency’s national reporting and learning system recorded 129 419 surgery related events in 2007.³ In the United States, the state of Minnesota (with less than 2% of the US population) reported 21 surgeries in the wrong site during one year (October 2007 to October 2008).⁴ The real situation is probably even worse though, because most safety incidents are not reported.⁵

In June 2008, WHO launched the Safe Surgery Saves Lives campaign.² This included a "surgical safety checklist" (www.who.int/patientsafety/safesurgery/en/) to ensure that the entire operating theatre team has a common understanding of the patient and the surgical procedure, and that evidence based interventions such as antibiotic prophylaxis or deep vein thrombosis prophylaxis are reliably given.² The 19 item checklist is completed in three stages—before induction of anaesthesia (sign in), just before skin incision (time out), and before the patient leaves the operating theatre (sign out). Items on the checklist must be verbally confirmed with the patient and other team members. The WHO Safe Surgery Saves Lives Study Group has published a study of 3733 patients before implementation and 3955 patients after implementation of the checklist.^{6 7} After implementation, deaths were reduced by 47% (from 1.5% to 0.8%, P=0.003) and in-hospital complications by 36% (from 11% to 7.0%, P <0.001). Improvement was seen across the eight study hospitals, which were based in high, middle, and low income countries. The authors of the study make it clear that the mechanism for the observed improvements in outcome is unclear and is almost certainly multifactorial. They also admit that part of the improvement might result from the Hawthorne effect—an improvement in performance as a result of the subjects’ knowledge of being observed. However, the study produced what seem to be robust results across a range of settings. On the basis of these results, the National Patient Safety Agency has issued an alert mandating that an adapted version of the WHO checklist is completed for every patient undergoing a surgical procedure in England and Wales, with full implementation by February 2010.⁸ How hospitals will be assessed to ensure that they use the checklist by this date is not mentioned.

Several factors need to be taken into account in the attempt to translate the WHO study’s impressive findings into practice. Firstly, mandatory use of the checklist may not deliver the same impressive results as the voluntary WHO study. Some clinicians will think the checklist implies that their practice is unsafe. They will cite their own results and lack of catastrophes to support their resistance. In addition, certain aspects of care may be delegated to others; for example, a junior doctor who rarely attends operating lists may be blamed if prophylaxis for deep vein thrombosis is not given.

Secondly, in addition to using the checklist, team introductions, briefings, and debriefings were also used in the WHO study, but the exact process and adherence were not described. Briefings and debriefings at the beginning and end of the theatre list are considered good practice by the National Patient Safety Agency in the supporting information to its alert. Safety briefings enable members of the team to introduce themselves to each other and the list of patients, their order, and potential problems—such as the need for special equipment and patient positioning— to be discussed. Such briefings may have contributed to the success of the intervention in the WHO study as a whole. Without proper introductions, team members may work together all day without knowing each other’s names. It is much harder to speak up, ask a question, or voice a concern in the absence of a modest degree of familiarity. Despite initial scepticism from doctors, briefings are popular with nursing and other theatre staff. Briefings improve team communication and reduce errors and unexpected delays.⁹ Poor team work was associated with an increase in complications and deaths (odds ratio 4.82, 95% confidence interval 1.30 to 17.87) in an observational study of 293 surgical procedures in four US hospitals.¹⁰ In another single centre US study, surgeons reported an 82% reduction in unexpected delays after the introduction of briefings.¹¹

Thirdly, the WHO study took place in only a few of the operating theatres in each study hospital and was led by people with an interest in making the checklist work. For successful implementation along the lines of the National Patient Safety Agency alert, a similar method should be considered. This would enable problems to be resolved by enthusiastic teams before they spread to other areas. The checklist may require changes to existing procedures to avoid duplicating paperwork. Enhancements to the checklist are encouraged but removal of items is not. Long checklists are less likely to be completed so care should be taken in adding new items.

Briefings and checklists should take minutes and not cause delays. In theory, any team member can lead the briefings and safety checks. In our experience the operating surgeon is best suited to lead the safety briefing at the start of the list. We have also found that a circulating nurse or anaesthetic assistant is the best person to ensure that the WHO checklist is completed for each patient. Completion of the checklist must not become a passive tick box exercise—all team members must actively take part, and staff will need training as team members change.

None of these problems of implementation is insurmountable. Surgical teams, anaesthesia teams, and theatre teams all have different hierarchies and cultures, but if this initiative is to succeed, all will have to take part and accept changes to their working practices. Collection of data and feedback to individuals and teams showing improvements in practice and patient outcomes will help in the battle for hearts and minds that will be essential for the spread and sustained use of checklists.

Error is inevitable in systems that rely on human performance. Complexity of care in the operating theatre has evolved beyond the limits of individual performance. Briefings and checklists have been shown to improve collaborative teamwork, minimise surprises, and lead to a smoother safer day in the operating theatre. Try asking your neighbour—"If we were going to operate on you, would it be a good idea to take a few minutes to ensure all the operating theatre team knows the plan and we have the correct equipment?"—the answer is predictable.

Cite this as: BMJ 2009;338:b220

¹ North Bristol NHS Trust, Bristol BS10 5NB, ² Kaiser Permanente, CO 80439, USA

Research, doi:10.1136/bmj.b157

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Competing interests: JS, JP, and AMP use safety briefings and checklists. They were all involved in the UK Safer Patients Initiative funded by the Health Foundation. ML does work for Pascal Metrics, a safety consulting group.

Provenance and peer review: Not commissioned; externally peer reviewed.

References

1. Weiser TG, Regenbogen SE, Thompson KD, Haynes AB, Lipsitz SR, Berry WR, et al. An estimation of the global volume of surgery: a modelling strategy based on available data. Lancet 2008;372:139-44.[CrossRef][Web of Science][Medline]
2. World Health Organization. Safe surgery saves lives. 2008. www.who.int/patientsafety/safesurgery/en/.
3. National Patient Safety Agency. National reporting and learning system. Putting patient safety first. 2008. www.npsa.nhs.uk/nrls/.
4. Minnesota Department of Health. Adverse health events in Minnesota. Fifth annual public report. 2009. www.health.state.mn.us/patientsafety/ae/09ahereport.pdf.
5. Sari AB, Sheldon TA, Cracknell A, Turnbull A. Sensitivity of routine system for reporting patient safety incidents in an NHS hospital: retrospective patient case note review. BMJ 2007;334:79.[Abstract/Free Full Text]
6. Haynes AB, Weiser TG, Berry WR, Lipsitz SR, Breizat AH, Dellinger EP, et al. A surgical safety checklist to reduce morbidity and mortality in a global population. N Engl J Med 2009 Jan 14 [Epub ahead of print] doi:10.1056/NEJMsa0810119.
7. Moszynski P. Surgical checklist reduces complications by one third. BMJ 2009;338:b157.[Free Full Text]
8. National Patient Safety Agency. Patient safety alert. WHO surgical safety checklist. 2009. www.npsa.nhs.uk/nrls/alerts-and-directives/alerts/safer-surgery-alert/.
9. Lingard L, Regehr G, Orser B, Reznick R, Baker GR, Doran D, et al. Evaluation of a preoperative checklist and team briefing among surgeons, nurses, and anesthesiologists to reduce failures in communication. Arch Surg 2008;143:12-7; discussion 18.[Abstract/Free Full Text]
10. Mazzocco K, Petitti DB, Fong KT, Bonacum D, Brookey J, Graham S, et al. Surgical team behaviors and patient outcomes. Am J Surg 2008 Sep 16, doi: 10.1016/j.amjsurg.2008.03.002. [Epub ahead of print.]
11. Nundy S, Mukherjee A, Sexton JB, Pronovost PJ, Knight A, Rowen LC, et al. Impact of preoperative briefings on operating room delays: a preliminary report. Arch Surg 2008;143:1068-72.[Abstract/Free Full Text]

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