A new 19-item checklist for safe surgery from the World Health Organization (WHO) aims to improve communication and cohesiveness among team members at three key mileposts:
- Before anesthesia is induced—“Sign In”
- Before the skin incision—“Time Out”
- Before the patient leaves the OR—“Sign Out”
Wrong-site surgery is devastating—for the patient and family, of course, but also for the surgical team. Almost always, such error is the result of poor surgical process and ineffective communication among members of the surgical team. Now, WHO is working to improve the surgical process and team communication around the globe—with the goal of eliminating error in the operating room (OR). Is your hospital or clinic following through?
First, some background
After a spate of wrong-site surgical events that were covered intensively by the national media, including a highly publicized wrong-side brain surgery at Rhode Island Hospital in 2001, The Joint Commission in July 2003 designated elimination of wrong-site surgery as a National Patient Safety Goal. The Commission’s Universal Protocol, or UP, including the preprocedure “Time Out,” was made standard practice for all surgical procedures both in the main OR and at other care sites. (Editor’s note: The Joint Commission issued a revised Universal Protocol in January; you can read it, and considerable background on this safety effort, at http://www.jointcommission.org/PatientSafety/UniversalProtocol/.)
The 3-step UP
The Universal Protocol calls for the surgical team to take three steps preoperatively:
- confirm the patient’s identity using at least two identifiers
- mark the operative site
- take a final “time out,” which requires “active communication among all members of the surgical team, consistently initiated by a designated member of the team, conducted in a “fail-safe” mode” such that the procedure is not started if a team member has concerns. The “time out” includes explicitly confirming 1) the identity of the patient, 2) what procedure is planned, and 3) the correct site of surgery.
There is more: The team should confirm the availability of all appropriate equipment, and members should be asked if they have any concerns about the plan.
This is not news to ObGyns and other surgeons; most practice sites have developed a checklist to ensure that the Universal Protocol is implemented. But, as experience with the Universal Protocol has evolved, it’s become apparent that the protocol should be expanded to include briefing and debriefing components.
Renewed focus on “Before” and on “After”
About one half of all surgical complications can be prevented, studies of surgical error suggest.1Communication failure and poor teamwork among members of the surgical team are a commonly observed cause of adverse surgical outcomes.2 To improve teamwork and reduce communication failure, many experts have urged that the Universal Protocol be expanded to include a preprocedure briefing and a postprocedure debriefing. Such a briefing process may reduce preventable errors in several ways:
- encouraging ongoing communication
- sharing information
- prioritizing tasks
- improving attention
- avoiding tunnel vision.
Enter the Checklist
Building on these ideas, WHO has developed a Surgical Safety Checklist that incorporates many of these best practices into a 19-item checklist (TABLE). It’s hypothesized—and hoped—that the checklist will improve teamwork and effective communication; foster adherence to optimal surgical practices; and improve the team’s ability to anticipate possible adverse events.
That hypothesis has been bolstered by the results of a recent study of 7,688 patients who were undergoing noncardiac surgery at any one of eight hospitals. Implementing the WHO Surgical Safety Checklist led to 1) a decline in surgical death—from 1.5% to 0.8% of surgeries (p= .003)—and 2) a reduction in overall complications from 11% to 7% (p < .001). Surgical-site infection was reduced from 6.2% to 3.4%, and unplanned return to the operating room declined from 2.4% to 1.8% of surgeries.3
The design of that study doesn’t allow us to identify, with precision, the reasons that using the checklist improved outcomes. It’s possible that the performance of members of the surgical team improved because they knew that they were being studied (the so-called Hawthorne effect). More likely, the structured, collaborative conversation prompted by the checklist improved the exchange of critical information and stimulated group decision-making, which, in turn, improved outcomes.
The World Health Organization offers a “Surgical Safety Checklist”*
|Sign in||Time out||Sign out|
|Nurse verbally confirms with the team: |
|Has antibiotic prophylaxis been given within the last 60 minutes? |
| Does patient have a: |
|This checklist is not intended to be comprehensive. Additions and modifications to fit local practice are encouraged.|