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BMJ 2010; 341 doi: (Published 16 November 2010) Cite this as: BMJ 2010;341:c6530

Surgical checklists prevent complications, save lives

When six academic hospitals in the Netherlands introduced a comprehensive system of checklists for surgical patients, complication rates fell from 27.3 per 100 patients (95% CI 25.9 to 28.7) to 16.7 (15.6 to 17.9) in three months. Deaths in hospital fell from 1.5% (1.2 to 2.0) to 0.8% (0.6 to 1.1). Both changes were significant. Complications and deaths remained essentially the same in five control hospitals. Surgical checklists should be elevated from a good idea to gold standard, says an editorial (p 1963). This large controlled study makes a persuasive case that checklist procedures improve surgical safety and save lives.

It took staff nine months to implement the new system, which required nurses, anaesthetists, surgeons, and operating assistants to fill in a total of 11 checklists covering each patient’s journey from admission, through surgery, to recovery, then discharge. All complications, including process errors such as a postponed procedure, were recorded, as before, on an established national register of adverse events. The checklists were associated with reductions in 11 of 12 categories of complications, including wound infections, dehiscence, cardiac and pulmonary problems, and urinary tract infections. Even factors more usually associated with surgical skill such as bleeding and anastomotic leaks were significantly less common in the three months after the new system was fully operational. It is not yet clear why—possibly surgeons had fewer interoperative distractions and interruptions after the changes.

Hospitals should make surgical checklists a priority now, says the editorial, while we wait for further studies exploring simpler systems. We also need longer studies to find out whether complication rates creep up again when staff become tired of ticking boxes.

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