The checklist that could save your life

Source: Best Health Magazine, December 2011

Scary scenario #1: A doctor in Ontario operates on a patient for a blood clot, drilling a nickel-sized hole in the right side of the patient’s skull. The only problem: The blood clot is on the left side.

Scary Scenario #2: While performing a presacral neurectomy (the surgical removal of a nerve or section of nerves in the abdomen) on a 28-year-old British Columbia woman for persistent painful menstrual cramps, medical staff leave a 1.8-metre roll of surgical gauze in her abdomen. She suffers from an abdominal infection for three months before undergoing a second surgery that reveals the source.

Scary scenario #3: After 20 hours of labour, a 34-year-old B.C. woman gives birth by Caesarean section, only to be hit with sepsis’a blood infection generated in hospital’that very nearly kills her. Seventeen days later, she is released from hospital, feeling lucky to be alive.

These are all real-life examples of the kinds of surgical complications that have occurred in Canadian hospitals. An estimated two million surgeries are performed in this country every year, and in about 11 percent of those cases complications occur, resulting in pneumonia, stroke and kidney failure, among others. Such problems are both devastating to patients and costly to the health-care system, says Hugh MacLeod, CEO of the Canadian Patient Safety Institute.

But a potent new tool has recently emerged in the fight to keep a lid on surgical complications. It isn’t an innovative new drug or an expensive piece of equipment. It’s a simple, low-cost procedure developed by the World Health Organization called the Surgical Safety Checklist. And it’s surprisingly effective.

A 2009 study published in the New England Journal of Medicine found that in eight hospitals around the world, complications from surgery dropped by about a third (to seven percent from 11 percent) when operating room teams followed the step-by-step checklist. And the in-hospital death rate dropped by an astounding 40 percent. In fact, Dr. Bryce Taylor, former chief surgeon at the University Health Network (UHN) in Toronto and leader of the Canadian arm of the study, estimates that simply by implementing the checklist in all Canadian hospitals, more than 60,000 patients each year could be spared surgical complications.

Comprehensive checklists have long been used in the aerospace industry and other fields where lives are at risk. The trend can be traced back to 1935, when Boeing’s B-17 long- range bomber was introduced with much fanfare’and then crashed on its test flight due to pilot error, killing two men. The highly complex flying machine, concluded one newspaper, was simply ‘too much plane for one man to fly.’ But a group of test pilots remained unconvinced. They suggested using a step-by-step checklist to ensure that basic procedures were followed before takeoff. The B-17 went on to give the Allies a solid edge in the air during World War II, and the use of checklists became commonplace for pilots from then on.

The Surgical Safety Checklist operates on the same principle, requiring the surgical team to double-check 19 different items before and after surgery. Examples of these items include:
‘ Whether antibiotics have been administered at the correct time prior to surgery (important in preventing infection)
‘ Whether the appropriate medications and fluids are available in the OR
‘ Whether the area for surgery has been marked on the patient’s body
‘ Whether an instrument and sponge count has taken place

Ensuring that these steps have been taken is important because the complexity of medical care today increases the potential for human error, says MacLeod. ‘The medical interventions we’re doing today, we didn’t even dream about 20 years ago. The team has to be well-prepared and well-versed.’

Why safety checklists work

But that double-checking is only part of why the Surgical Safety Checklist is effective, says Taylor. Canadian hospitals have been using ‘a variety of checklists for years, but they have been mostly aimed at the role of one particular group, such as operating room nurses, who are responsible for ensuring that patient identity is confirmed and that instruments are ready. The WHO checklist, he points out, requires that everyone on the surgical team run through the checklist together, in the presence of the patient, before surgery. Part of the reason it works so well, he says, is that it changes the dynamic in the OR, by ‘flattening the pyramid’ and making it more likely that medical staff working under surgeons will speak up about concerns or issues.

He compares it to the situation in a cockpit. ‘If a cockpit consists of a captain and other people who are subservient and who are afraid to tell the captain what they know, that makes for a dangerous situation,’ he says. The same holds true in the operating room. ‘People who know a lot’the anesthesiologist, the nurses and other people in the operating room’are sometimes afraid to speak. Or they’re speaking in such couched terms that they can’t accurately convey what’s on their mind. If you create a new culture where everybody has a role to play and they’re accountable and they speak up, it changes the dynamic.’

MacLeod aims to see checklists used routinely in hospitals. ‘I would like to see every hospital and every team, for every surgery, using the checklist,’ he says. As it stands, the Surgical Safety Checklist became a required operational practice (ROP) in Canadian hospitals this year, meaning failure to use it could result in a loss of hospital accreditation. But that doesn’t mean all hospitals and all doctors are actually using it. Some medical professionals are resisting the change, says MacLeod. ‘As with other initiatives, there will be degrees of take-up. But we do see take-up across the country, and at some institutions there is almost wall-to-wall acceptance. It’s a steady climb of progress.’

What you can do before surgery

If you’re going in for a surgical procedure, advises MacLeod, by all means ask whether your doctor is planning to use the checklist. ‘You have to sign the permission form for surgery,’ he says. ‘At that point, I suggest saying something like: ‘I’m assuming you’ll be using the surgical checklist.”’ If the doctor says no, there’s nothing wrong with asking ‘Why not?’ he contends.

Taylor concurs. In fact, he and other doctors at UHN were so impressed by the results of the checklist at their own hospital, Toronto General, that they decided early on in the study process to extend use of the checklist to UHN’s other two hospitals: Toronto Western and Princess Margaret. It is now used in the more than 23,000 operations performed in those facilities every year. Meanwhile, Taylor and other doctors have been promoting use of the checklist across the country, encouraging other hospitals and doctors to use them routinely.

‘It takes between two and three minutes to run through it before surgery,’ says Taylor. But it saves far more time and money if it helps pick up a dangerous issue and makes the treatment more efficient and better for the patient.

‘It’s not just that I’m obsessive-compulsive and I want to follow rules,’ he says. ‘All these things are set up for the benefit of the patient. After all, that’s why we’re here.’

This article was originally titled "The checklist that could save your life" in the December 2011 issue of Best Health. Subscribe today to get the full Best Health experience’and never miss an issue!