Nurses, Physicians Encouraged to Use Surgical Safety Checklist

The following article is from Nurse.com and written by Catherine Spader, RN, who is a contributing writer for Nursing Spectrum/NurseWeek

A surgical checklist study proved so successful at saving lives and reducing complications that the Institute of Healthcare Improvement is calling on every hospital in the country to use the checklist at least once before April 1.

The new study, published in the Jan. 29, issue of the New England Journal of Medicine, found the World Health Organization's Surgical Safety Checklist, a simple but comprehensive checklist used during major surgeries, significantly reduced incidences of surgery-related deaths and complications.

"You don't rely on memory to complete a complicated recipe, so why would you rely on memory for a complicated surgical procedure that is so critical to the individual lying on the OR table?" said Fran Griffin, RRT, MPA, director at the Institute for Healthcare Improvement, based in Cambridge, Mass.

The study collected data from 7,688 patients at eight hospitals in the WHO's six worldwide regions. Researchers found major complications that followed surgery fell from 11% in the baseline period to 7% after introduction of the checklist. Inpatient deaths that followed major operations fell by more than 40% (from 1.5% to 0.8%).

Outcomes of the checklist's use are so impressive the IHI is sponsoring the WHO Surgical Safety Checklist Sprint initiative. The goal is to have every hospital in the country test the checklist at least one time by April 1. The ultimate goal is for facilities to move toward full implementation of the checklist during all surgical procedures.

A Conversation Piece

Most checklists in use today tend to be silent paper exercises in which a lone nurse checks off boxes. In contrast, the WHO checklist is a tool of communication and functions as a list of team talking points.

"The most important thing the checklist does is make people think as a team about all the steps they need to ensure what will happen," said Atul Gawande, MD, coauthor of the checklist study and a surgeon at Brigham and Women's Hospital and associate professor at the Harvard School of Public Health in Boston.

This checklist concept does not revolve around a piece of paper but a conversation in which one person, usually a nurse, takes the lead. Everyone on the team has to verbally respond to the points on the list, including physicians, anesthesiologists, and other nurses.

The patient also is considered a team member and an active participant in the checklist conversation. During the preprocedural portion of the checklist, the patient must verbally confirm his or her identity, the surgical site, procedure, and consent.

Becoming A High Reliability Industry

Evidence from high reliability industries, such as nuclear power and aviation, has shown an oral check is more likely than a written check to capture and prevent errors, according to Alex B. Haynes, MD, MPH, lead author of the study and researcher at Harvard School of Public Health.

In fact, the checklist doesn't need to be documented on a piece of paper at all. The checklist conversation can be adapted to suit the needs and resources of individual facilities and can be followed from a poster visibly displayed in the OR.

"It's not intended to be a form of documentation or regulation," said Haynes who also is a surgeon at Massachusetts General Hospital in Boston. He adds that organizations have the option to adapt it to serve that purpose if they choose.

Making it Work

Adapting and implementing the safety checklist can require hurdling some obstacles, according to Jodi Bloom, RN, BSN, CNOR, staff nurse in the OR at University of Washington Medical Center in Seattle, the only U.S hospital that participated in the checklist study.

"Many of us thought the checklist conversation was just one more thing we had to do to get a case started," Bloom said. "Now we think it's an invaluable tool. It collectively forces everyone in the room to pay attention, focus on the patient, discuss the patient, and be on the same page."

The checklist conversation can take as little as two minutes to complete. "If you try it with one case, you learn very quickly how to best adapt it to your practice," said Bloom. "Our surgical teams were accustomed to performing timeouts, and this came to be incorporated into our practice as an extended timeout. Now it has become innate."

Another key to success is to test the checklist on a small scale first, such as with the cases of one surgeon who is enthusiastic about the concept. It also is a good idea to present the checklist concept to the entire OR staff before implementation and ask for and incorporate their input in adapting the list.