Surgical team in India calls for mandatory enforcement of WHO safety checklist

BMJ 2015; 350 doi: (Published 16 March 2015) Cite this as: BMJ 2015;350:h1462
  1. Ganapati Mudur
  1. 1New Delhi

A team of gastrointestinal surgeons in India has called for mandatory enforcement of the World Health Organization’s surgical safety checklist across the country, after implementing it in their own department and observing lower postoperative complications and mortality.

The surgeons at the Sir Ganga Ram Hospital in New Delhi documented a mortality rate of 10% among patients whose operations followed standard hospital safety protocols, compared with 5.7% among patients managed under the WHO surgical safety checklist.1

Their study is thought to be the first randomised controlled trial on surgical outcomes from a developing country. The 20 month study period covered a variety of gastrointestinal procedures, including bile duct excisions and hepatic resections, duodenal and gastric perforation repairs, small bowel resections and anastomoses, and laparascopic, open, and radical cholecystectomies.

Neeraj Chaudhary, a member of the team, told The BMJ, “All surgical teams are expected to rigorously follow safety checklists, and all surgical teams believe they are doing so, but there is this feeling that checklists are not always as strictly implemented as they could be.”

In adopting the WHO checklist, the study team deviated from the hospital protocol and asked surgical residents instead of nurses to read out and track each item on the checklist. The surgeons noted that this departure from routine may have contributed to “better compliance and better teamwork” between surgeons, anaesthesiologists, and other operating room staff, which in turn translated into the lower rates of complications and mortality.

“This may appear a trivial deviation from protocol, but nurses do not enjoy the same authority in India as they do in developed countries,” Chaudhary said. “Unfortunately, surgeons and others are likely to take a surgical resident more seriously than a nurse. This culture has to change—all hospitals do not have surgical residents. No matter who is in charge of the safety checklist, it needs to be always implemented as rigorously as possible.”

The team has called for mandatory “strict implementation” of the WHO checklist. Samiran Nundy, an emeritus gastrointestinal surgeon at the hospital, said, “All healthcare institutions should view this as the least expensive way to improve patient safety.”

However, doctors and public health specialists who have been campaigning for enhanced regulatory oversight of the healthcare sector, as well as Indian health ministry officials, said that the government had limited leverage on proposals to enforce checklists.

Although the Indian parliament passed a legislation called the Clinical Establishments Act in 2010 to regulate healthcare institutions, it remains largely unimplemented.2 In 2013 the health ministry asked a panel of experts to design a template for “minimum standards” for healthcare institutions. Sunil Nandraj, a health systems researcher in New Delhi and a panel member, told The BMJ, “The minimum standards will mainly deal with physical infrastructure and human resources. The checklist could be part of standard surgical protocols, but the agreement and acceptance of the minimum standards is still a work in progress.”

A senior health official who asked not to be named said, “The Clinical Establishments Act would be a possible route to introducing and enforcing standards, but health is a state subject in India, and only eight states have so far taken up the act.”

Suresh Vasistha, a consultant laparascopic surgeon and president elect of the Association of Surgeons of India, told The BMJ, “There is a need for concerted efforts to document complications—most studies on this topic from India have looked mainly at correlations between complications and factors such as severity of illness or the surgical procedure being used, not the process of surgery itself.”

He said that in 2009 the Association of Surgeons of India printed and distributed copies of surgical safety checklists to medical colleges, corporate hospitals, and its own members. “We want this to be uniformly followed,” he said.


Cite this as: BMJ 2015;350:h1462


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