Why Your Hospital Should Be Using A Pre-Op Checklist

Patrick DeHeer DPM FACFAS

I drive several hours each week to my various offices each week and use the time to listen to audio books. I just finished listening to an excellent book called The Checklist Manifesto by Atul Gawande, MD.

The Checklist Manifesto discusses the use of checklists in several fields such as aviation, construction, financial, the restaurant business and others. Being a general surgeon, Dr. Gawande discusses the use of a checklist in medicine or I should say the lack of use of a checklist in medicine.

The World Health Organization (WHO) asked Dr. Gawande to help develop measures to reduce complications and deaths around the world. The enormous task came down to a simple checklist of three pause points with 19 overall checkpoints. The pilot study occurred in eight cities around the world with hospitals of all types of economy and size. There was certainly pushback from staff (especially the surgeons) at these facilities. The well-orchestrated trial won over even the staunchest adversaries.

The initial trial consisted of approximately 4,000 surgical patients at these facilities. With the use of a checklist, major surgical complications decreased by 36 percent and deaths decreased by 47 percent. Infections decreased by almost 50 percent and returns to the operating room decreased by 25 percent. Based on observational data, there should have been 435 serious complications in this initial data group but this number decreased to 277. The checklist therefore saved 158 patients from some type of serious complication and prevented 27 deaths.

Let me state this again just to make it crystal clear. These unbelievable improvements in a very short period of time were all due to a simple checklist and nothing else.

Every hospital or surgery center where I operate is supposed to do a “timeout” (checklist prior to surgery). Basically, the checklist consists of the patient name, procedure, side of operation (right or left) and the pre-operative antibiotic. I started really paying attention and realized they do not all do this.

Why are we so reluctant to use something so simple and so effective? Dr. Gawande discusses this often in the book but it is really astonishing to me. As Dr. Gawande covers in the book, a good checklist is not all-inclusive. It covers critical points and understands that the person who uses the list knows the field well but reminds the person of the critical steps that may go overlooked in a stressful situation, much like an airplane engine going out.

One of the key factors in the WHO checklist is to establish a team approach in the operating room in which everybody on the team has a say and will be heard by the others on the team. Having multiple people working on the same goal results in significant improvement in patient care. Is that not why we all do what we do?

This makes me wonder about the use of more checklists for my everyday practice and also for operative techniques. Could checklists provide me with even better outcomes and even more consistent results? How should I implement them? Where do I start? How about you?

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