The Importance Of Checklists In Surgery

Complex surgeries require a large team of healthcare professionals, including surgeons, anesthesiologists, nurses, technicians and others, to collaborate closely with everybody playing his/her part. However, even with the most competent and best trained healthcare professionals and the best technology available, things sometimes fall between the cracks and complications occur. To prevent this, a top surgeon suggests that something as trivial as a checklist can make a huge difference.

Studies show that the death rate in surgery is 0.4-0.8%, while the rate of complications varies between 3% and 17%. At least half of these complications are avoidable. These complications include acute renal failure, bleeding within the first 72 hours after surgery, cardiac arrest requiring cardiopulmonary resuscitation, coma of 24 hours’ duration or more, deep-vein thrombosis, myocardial infarction, unplanned intubation, ventilator use for 48 hours or more, pneumonia, pulmonary embolism, stroke, major disruption of wound, infection of surgical site, sepsis, septic shock, the systemic inflammatory response syndrome, unplanned return to the operating room, vascular graft failure, in addition to death.

In the new book The Checklist Manifesto, Dr. Atul Gawande stresses the importance of checklists in preventing surgical complications. This approach requires surgical teams to stop at three crucial points before and after surgery and get information from everyone involved in the surgery.

For example, before induction of anesthesia, members of the team orally confirm that “the patient has verified his or her identity, the surgical site and procedure, and consent, the surgical site is marked or site marking is not applicable, the pulse oximeter is on the patient and functioning, all members of the team are aware of whether the patient has a known allergy, and the patient’s airway and risk of aspiration have been evaluated and appropriate equipment and assistance are available, and if there is a risk of blood loss of appropriate access and fluids are available.”

Before the surgery actually starts, a time-out is taken so that the entire team orally “confirms that all team members have been introduced by name and role, confirms the patient’s identity, surgical site, and procedure, reviews the anticipated critical events (surgeon reviews critical and unexpected steps, operative duration, and anticipated blood loss, anesthesia staff review concerns specific to the patient, nursing staff review confirmation of sterility, equipment availability, and other concerns), confirms that prophylactic antibiotics have been administered ≤60 min before incision is made or that antibiotics are not indicated and confirms that all essential imaging results for the correct patient are displayed in the operating room.”

At sign-out, before the patient leaves the operating room, “the nurse reviews items aloud with the team, the name of the procedure as recorded, that the needle, sponge, and instrument counts are complete (or not applicable, that the specimen (if any) is correctly labeled, including with the patient’s name, and whether there are any issues with equipment to be addressed. Moreover, “the surgeon, nurse, and anesthesia professional review aloud the key concerns for the recovery and care of the patient.”

While it sounds very cumbersome, going over the list takes just two minutes but can "get the dumb stuff out of the way" and allow the team to focus on the most demanding tasks, according to Gawande.

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