Primum Non Nocere – Surgical Checklists
From the Ad Hoc Neurosurgical Committee for Patient Safety
On July 13, 2009, a freak aviation accident occurred when a flock of geese flew into the engines of US Airways Flight 1549 travelling from LaGuardia Airport in New York to Charlotte, North Carolina. The Airbus immediately lost engine power and was successfully guided to an emergency landing on the Hudson River. The survival of all of the passengers was immediately heralded worldwide, and Captain Sullenberger was declared a hero. Both Captain Sullenberger and First Officer Skiles were impeccable pilots, but repeatedly credited the flawless teamwork of both pilots and all the flight attendants who wound up saving the lives of all 155 occupants. The cockpit voice recorder captured the entire event. First Officer Skiles calmly read off the emergency checklist from the Quick Reference Handbook with Captain Sullenberger responding to each item. Once in the water, Skiles remained alone on the flight deck running the evacuation checklist while Captain Sullenberger made his way through the cabin checking to make sure that every passenger evacuated the plane before he too left the plane. Their systematic approach to make sure each and every item on the emergency checklist was attended to contributed to an extraordinary outcome.
In November of 1999, the Institute of Medicine published the report To Err is Human.1 This report reviewed data suggesting that between 44,000 to 98,000 people die in hospitals each year as a result of medical errors that were potentially preventable. The media attention generated by this report led to a multifaceted attempt to improve patient safety and decrease medical errors in medicine. Medical professionals smartly examined the best practices of industries like the airline industry, which had long and positive safety records. In an attempt to improve patient safety and outcomes, best systems were adopted to be used in medical practice. One of the tools implemented was the safety checklist. The implementation of the first widely publicized checklist, published in 2006, found that the implementation of a safety checklist used in the insertion of central venous catheters decreased the infection rates per 1000 catheter days from 2.7 to zero.2
During this period, The World Health Organization’s Patient Safety Programme created an initiative to improve the safety of surgery globally. Again using the airline industry as a guide, a surgical safety checklist to reduce morbidity and mortality in surgery was designed. In 2009, a widely cited article was published in the New England Journal of Medicine,3 which resulted in widespread adoption of safety checklists in operating rooms in many hospitals across the U.S. By 2009, 10% of all hospitals in the U.S. had adopted a surgical safety checklist. Despite this development, there has been resistance to its adoption by many surgeons, and neurosurgery has only recently begun to actively focus on patient safety issues.4
What lessons and key points have been learned since this time, and why has there been resistance?
Surgery involves complex decision-making at multiple levels. Surgeons know that doing the “same thing every day” improves outcomes and frequently go through their own “mental checklist” on every case. Although we each may have done a similar case hundreds of times, it is easy to miss an item on a mental checklist, particularly in an emergency situation. On the other hand, formalized checklists alone cannot prevent all surgical errors. The key to increasing patient safety and efficiency with the use of a surgical checklist centers on engaging every member of the entire operating team. By changing the culture of the operating room, attention is focused on each individual patient by every member of the operating team prior to beginning surgery. Adherence to fundamental aspects of surgical care such as following antibiotic protocols and communication between members of the surgical team has been shown to be improved with the use of the surgical checklist. I recently asked one of our operating room nurses why she favored the surgical checklist, and she quickly responded, “I feel it gives everyone in the room one last chance to make sure we are not making any simple mistakes and focus all our attention on the patient.”
So why is such a simple process not embraced by all? One suggestion has been that the Surgical Checklist has arrived in the operating room from “outside-in” and “top-down.”5 How the checklist is rolled out within the institution seems to make a difference to its adoption and implementation. The surgeon and each team member needs to understand the “whys” of what they are doing on a daily basis, and take ownership of the checklist. To be effective, the checklist must first be made relevant to each individual institution. In addition to being relevant, the checklist must be concise, so that it is manageable while it remains comprehensive. In neurosurgery, we may wish to modify checklists to reflect the specific surgical practice. For example, a valuable tool for a lumbar surgical procedure might incorporate specific items to prevent wrong level surgery, such as standardizing x-ray imaging and marking levels.
The operating room culture has traditionally been hierarchical, and incorporating a checklist requires a dedicated approach to promoting teamwork, which has been a cultural change for many. Several studies have shown that even if a change in safety cannot be measured, the operating room team “feels” that safety has been improved by engaging all members of the surgical team who become responsible as a group for the patient’s safety.
Surgical complications and errors are devastating to patients, the surgeon and all members of the operating team. While a checklist is not a panacea, incorporation of a surgical checklist is a crucial component of a comprehensive operating room patient safety program. A surgical checklist is an efficient and cost-effective means of creating a culture of safety and improving team dynamics in the operating room with the ultimate goal of reducing preventable errors.
1. Kohn, L.T., Corrigan, J.M., Donaldson, M.S. To err is human: Building a safer health system. Washington, DC: National Academy Press, 2000.
2. Pronovost P., Needham D., Berenholtz S., et al. N Engl J Med 2006; 355: 2725-32.
3. Haynes A.B., Weiser T.G., Berry W.R., et al. N Engl J Med 2009; 360: 491-499.
4. Zuckerman S.L., Green C.S., Carr K.R., et al. Neurosurg Focus 2012; 33: E2, 1-11.
5. Gawande, A. The Checklist Manifesto, Picador, 2009.