Verbal Checklist May Cut Surgical Errors

Jan. 14, 2009— -- Surgeons who used a verbal checklist before, during and after operations were able to drastically reduce complications, according to a new study that some doctors say may be too good to be true.

The year-long study at eight hospitals worldwide showed death rates dropping by nearly half, to 0.8 percent from 1.5 percent, and other complications falling to 7 percent from 11 percent after surgical teams started using a verbal checklist.

"The take-home message is that a relatively simple tool, a checklist ... can help to improve team function, ensure the performance of known safety practices, and ultimately reduce complication and death following surgery," said lead study author Dr. Alex B. Haynes, a surgeon and research fellow at the Harvard School of Public Health and Massachusetts General Hospital.

For the study, eight hospitals in places from Seattle to Ifakara, Tanzania, adopted a list of steps to confirm before, during and after operations. These included steps such as knowing whether the patient has an allergy, confirming that antibiotics were given close enough to the start of surgery, and having accurate counts of surgical tools used.

Researchers compared surgery outcomes before and after adopting the checklist to see how much it affected the results for patients operated on in the hospitals.

"The idea of a checklist seems kind of brainless, right? We must be doing this all the time, but in fact, it's new to us in medicine," Dr. Atul Gawande, associate professor at HSPH and a surgeon at Brigham and Women's Hospital in Boston told ABC News medical correspondent John McKenzie. "The reason we ended up focusing on the idea of a checklist is because of work that a researcher at Johns Hopkins did showing that a simple checklist for I.V.'s in the intensive care unit could reduce their infection rate massively.

"Putting in that checklist in the state of Michigan saved more than 1,500 lives a year, $200 million dollars. We said if they can do that for something as simple as an I.V., we could possibly make a lifesaving checklist for surgery, 2,000 different kinds of surgical procedures."

Many hospitals presently use checklists to help avoid complications in surgery. Haynes said the novelty of the checklist used in the current study, which was developed by a consortium of health practitioners under the auspices of the World Health Organization, was that it was verbal, rather than a paper checklist, and required more interaction between surgical team members.

The idea for the checklist actually came from aviation.

"We followed almost the way they do in aviation. There is a checklist part for before you take off, there's a checklist for in the air, there's a checklist before landing. And we did the same thing," said Gawande.

Haynes noted that the checklist differed from those used in most hospitals now.

"This checklist is different in that it's a team exercise among all the members of the operating team," Haynes said.

Surgery Checklists Are Important, Doctors Say

Dr. Thor Sundt, vice-chair of the department of surgery at the Mayo Clinic, called these checklists "the most important research that we can do in clinical medicine today."

"While there tends to be much more interest in technological breakthroughs and new drugs, these kinds of interventions probably have a greater potential to impact health care than any other. I am sure that we can save more lives with checklists than we can with robotics, etc."

Sundt said that the primary barrier to developing more studies like this is the difficulty in getting them published in medical journals.

While checklist studies may face obstacles in publication, doctors praised them for the obstacles they help overcome in maintaining patient safety.

"The true strength of the intervention in patient safety is demonstrated by the fact that even without 100 percent compliance and adherence to the study, there was a dramatic benefit," said Dr. David Cronin, director of liver transplantation at the Medical College of Wisconsin.

But for others, the results, when combined with compliance with the checklist, made them suspicious of the alleged benefits.

"The study is interesting, but the data and conclusions are illogical, which makes me highly distrustful of it," said Dr. Jeff Punch, chief of the division of transplantation at the University of Michigan.

Punch said that the interventions the checklist targets should not have had the effect that they did, since many of the problems they seek to prevent are quite rare.

"I am a supporter of these sorts of checklists," he said. "We use similar checklists at our hospital and I think they make things more efficient and safer, but I do not think the magnitude of the effect is large."

Dr. John D. Birkmeyer, a professor of surgery at Michigan, speculated that it was feedback, rather than the checklist itself, which aided the surgeons.

"In my opinion, the simple act of tracking outcomes and providing timely feedback to hospitals and surgeons was the most likely explanation for the important reductions in morbidity and mortality observed in this study," he said.

Unfortunately, Haynes noted, there is no way of knowing now whether the gains researchers observed in the hospitals will continue. Data collection has stopped, and while Haynes said hospitals in the study still use the checklist, they do not have numbers to confirm that surgical complications have stayed lower.

Surgery Must Never Be 'Routine'

A lack of urgency, said Dr. David Euhus, a professor of surgery at the University of Texas Southwestern Medical Center, brings about the dreaded complications.

"Surgery is a complex undertaking that requires a high level of communication between everyone involved," he said. "Because it is performed so frequently and usually with excellent results we can mistakenly perceive it as 'routine.' It is never routine and exacting attention to details is always required."

For his part, Haynes remains optimistic about the future of the checklist, and emphasized the global development and potential for global use of the WHO checklist as its most important feature.

"It really speaks to the global nature of healthcare today," he said. "The issues facing healthcare practitioners are really similar in all corners of the world, rich and poor in every environment."