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Surgeon's Checklist Saves Lives

WEDNESDAY Jan. 14, 2009 -- A simple checklist that ensures everyone in the operating room is on the same page reduces complications and saves lives, researchers report.

The need for improving safety in surgery is vital since there are some 230 million major operations worldwide each year, 60 million of them in the United States. In fact, the average American undergoes nine surgical procedures in their lifetime.

"Using a surgery checklist designed for safety cut the complication and death rate by a more than a third," said lead researcher Dr. Atul Gawande, an associate professor of health policy and management at the Harvard School of Public Health and a surgeon at Brigham and Woman's Hospital, Boston. "The safety of surgery has now become a major public health concern."

To aid in reducing surgical complications and deaths, Gawande's team developed a one-page checklist that can be read aloud like a pilot's checklist before take off and landing. The list is designed to make sure that all those in the operating room communicate important patient information during what is known as "timeouts": before anesthesia is started; before the first incision is made; and before the patient is rolled out of the operating room.

While each surgery is different, there are common safety points for all procedures, Gawande said. "If we miss them, people are harmed," he said.

One item on the list is making sure an antibiotic is given before the first incision; this alone can reduce the risk of complications by half, Gawande noted. Other items include making sure that everyone in the operating room has been introduced and knows each other's name, that the team is briefed on the amount of blood loss expected, and how long the operation will take.

The report is published in the Jan. 14 online edition of the New England Journal of Medicine.

To test the validity of the checklist, Gawande's team collected data on 7,688 patients. They collected data on 3,733 patients before using the checklist and on 3,955 patients after surgeons started using the checklist.

During the year of the study, the rate of major complications in operating rooms dropped by more than a third when the checklist was used -- from 11 percent to 7 percent.

More importantly, deaths dropped by more than 40 percent when the checklist was introduced, from 1.5 percent to 0.8 percent, the researchers found.

The value of the checklist was seen in hospitals worldwide, with similar reductions in death and complications. The checklist was used in hospitals in: Seattle; Toronto; London; Auckland, New Zealand; Amman, Jordan; New Delhi, India; Manila, Philippines; and Ifakara, Tanzania.

"I have been using the checklist for a year, and I don't get through a week when we don't catch something. Often they are small things, but I've seen it save the life of a patient," Gawande said.

Gawande noted that the checklist is being adopted by hospital associations in five states including Washington, North Carolina, South Carolina, Indiana and New York. In addition, the U.K., the Philippines, Ireland and Jordan plan to adopt the checklist nationwide, he said.

Dr. Jeffrey Salomon, an assistant professor, surgery at Yale University School of Medicine, noted that many surgeons are starting to use a form of checklist.

"The 'timeout' is mandated in surgery in this country since Medicare indicated that it would not reimburse for a variety of errors such as wrong-side surgery," Salomon said.

"It initially seemed a little juvenile to surgeons, but has come to be well-accepted by all operating room personnel," he said. "There is little question that it helps reduce avoidable errors, just like an airplane pilot has a checklist to reduce the same."

More information

For more information on the checklist, visit the World Health Organization.

Posted: January 2009


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