Checklists can reduce errors in intraoperative emergencies by 75%, says expert

BMJ 2013; 346 doi: (Published 29 April 2013) Cite this as: BMJ 2013;346:f2767
  1. Krishna Chinthapalli
  1. 1BMJ

Dealing with intraoperative emergencies can be much improved by use of a checklist, says Atul Gawande, the lead adviser on the World Health Organization’s Safe Surgery Saves Lives programme and a surgeon at Brigham and Women’s Hospital in Massachusetts.

At a talk at University College London’s Institute of Child Health in London on 26 April, Gawande outlined the results of his group’s study earlier this year.1 He said, “We tested this in a randomised trial by bringing teams into a simulator . . . They went from a 25% likelihood of missing key lifesaving steps to a 6% likelihood: a 75% reduction in errors.”

He said he believed that crisis checklists were the next step in surgical safety, following on from his earlier development of WHO surgical safety checklists, which are used for routine checks before, during, and after an operation. WHO believes that the use of these checklists in every operation would prevent over half a million deaths, after a number of studies confirmed reductions in complications and mortality.2

“If we are getting our act together about how we handle prevention in our normal cases, then how do we do when things go abnormal, when an emergency crisis develops? Multiple studies have shown how chaotic and how poorly disorganised we typically find ourselves,” Gawande noted.

“And so we worked with the same team and then a wide range of experts to identify the most common ways in which disasters happen in the operating room. Using the same design format and structure of cockpit checklists, we designed them to be easily read and walked through so that steps might not be forgotten.”

Gawande and colleagues developed the new operating room crisis checklists at Ariadne Labs, part of the Harvard School of Public Health. Twelve checklists cover topics such as anaphylaxis, cardiac arrest, failed airway, haemorrhage, hypotension, and unstable tachycardia.3 However, there has been criticism that they require clinicians to undergo instruction and training of clinicians, especially for use during an emergency, and that even with checklists key steps were missed.4

Gawande said that the checklists and an implementation guide were now being rolled out in the Partners Healthcare System in Boston; Stanford University’s medical centre; and the Kaiser Permanente managed care consortium. He called on clinicians in the UK health services to adopt them too, saying, “I have long valued the partnership across the Atlantic with the United Kingdom. You all have been pioneers in trying to bring systems of care that make substantial improvement in the ability of surgeons to get even better results.

“I see another [opportunity]: to take this next step and build in this one more system that makes us that much more coordinated, that much more effective, and that much more effortless in our ability to achieve great care.”


Cite this as: BMJ 2013;346:f2767