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Is WHO’s surgical safety checklist being hyped?

BMJ 2019; 366 doi: (Published 05 August 2019) Cite this as: BMJ 2019;366:l4700

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Re: Is WHO’s surgical safety checklist being hyped?

Safety checklists, believing in hype and lessons from the Tour de France

Urbach and Dimick question the miraculous results the WHO's surgical safety checklist have been credited with. I enjoyed the reference to the famed astronomer, Carl Sagan, that extraordinary claims require extraordinary evidence. I wonder if the authors are aware this quote was often used by Lance Armstrong, in the last days of his empire before his doping was exposed, to repel brave investigative journalists who dared question his incredible dominance of the Tour de France. The supposed mechanism of the associated reduction in mortality, ensuring that the team members, patient, and procedure are properly identified and confirming that the team has contemplated several processes of care should not be taken for granted.

Urbach and Dimick are correct in challenging the causal relationship and quality of some of the evidence. They question the plausibility of the effect considering that most of these pre-existing quality improvement processes had not been proven to reduce surgical mortality when applied individually. This brings us back to the Tour de France. The checklist has galvanised all the individual processes and provided a tangible focal point for all staff and like the philosophy behind the recent dominance of the British Tour Winners Sir Bradley Wiggins, Chris Froome and Geraint Thomas, the principle of the aggregation of marginal gains has been demonstrated with spectacular effect for surgical safety.

I agree with Haynes and Gawande that the checklist is a powerful tool and furthermore it serves as a useful surrogate marker of quality in surgical teams and institutions. A recent study continues the trend, where use of the checklist was associated with reduced peri-operative mortality, especially in low and middle Human Developmental Index countries. [1] Sceptisicm for causal relationships that seem to good to be true are always welcome in surgical outcomes research. However, I encourage the Yes side to embrace the wealth of extraordinary evidence behind the checklist. To paraphrase what Mr Armstrong boldly said to his growing doubters after his 7th and final Tour victory [2] ' the last thing I'll say for the people that don't believe in the checklist, the cycnics and the sceptics, I'm sorry you can't dream big and I'm sorry you don't believe in miracles.' Unlike the doping years of the Tour de France, let's hope the legacy of the checklist endures.

[1] Pooled analysis of WHO Surgical Safety Checklist use and mortality after emergency laparotomy.Br J Surg. 2019 Jan;106(2)

Competing interests: I was a collaborator and data validator on GlobalSurg projects which included use of the WHO checklist. I also came near to last place in the 2019 Etape du Tour.

08 August 2019
Donal B O'Connor
Adjunct Lecturer in Surgery
Trinity College Dublin