Similar to Aviation, Checklists Have a Place in Surgery

Orthopaedics involves a wide variety of invasive and complex procedures, and all surgical endeavors require patient safety. Compared to other industries, such as aviation and nuclear power, surgery is associated with a higher baseline risk for all types of complications. The fatality rate from complications is one per 10,000 surgeries. Comparatively, air travel has a fatality rate of one in 11 million, making it 1,100 times safer. As nearly 234 million operations are performed annually, there is a desperate need to reduce the mortality rate.

The practice of using checklists was pioneered by the aviation industry to help ensure the safety of passengers and improve pilot consistency and reactions to crises. American surgeon and writer Atul Gawande, MD, MPH, discusses the origins and applications of checklists in his book, “The Checklist Manifesto.” Checklists not only assisted with the safety of aviation but also made it simpler. Utilization of checklists was associated with routines that would focus attention toward critical steps, increasing efficiency.

Implementation of checklists is cost conservative and can result in significant reductions in both mortality and complication rates in various healthcare settings. However, surgery-specific checklist adaptations are relatively new, particularly in orthopaedics. Orthopaedic surgeons may benefit from the development of standard checklists for specific surgeries, such as total joint arthroplasty (TJA).

Beginnings of the Surgical Safety Checklist

In June 2008, the World Health Organization (WHO) launched the Safe Surgery Saves Lives campaign with the development of the Surgical Safety Checklist (SSC), which is the standard for surgery in North America and in Europe. Panesar et al., reported that in February 2010, all hospitals in the United Kingdom had applied the SSC for surgical care.

SSC’s impact on safety

Panesar et al., suggested that tools needed to be developed to help prevent patient safety incidents (PSIs). Researchers conducted a large registry-based study and reported that 21.1 percent of PSIs may have been prevented with use of the SSC. Haynes et al., demonstrated how use of the SSC was universally associated with decreased complication and mortality rates (11 percent to 7 percent and 1.5 percent to 0.8 percent, respectively). Similar results were reported by Vries et al., who also recorded decreases in complication and mortality rates after checklist implementation (27.3 to 16.7 per 100 patients and 1.5 percent to 0.8 percent, respectively).

In their evaluation of the effect of SSC implementation in an orthopaedic department, Boaz et al., observed a substantial decrease in rates of postoperative fever (10.3 percent to 5.3 percent). Russ et al., performed a study observing the effect of the SSC on the quality of procedure in the operating room (OR), concluding that application of the checklist enhanced communication, efficiency, and teamwork. To the contrary, Sewell et al., reported that use of the SSC was not associated with significant decreases in early complications and mortality in orthopaedic trauma patients.

A meta-analysis performed by Bergs et al., assessed the impact of the SSC on postoperative complications for orthopaedic surgeries. Observations included reductions in complication rates, surgical site infections, blood loss, unexpected returns to the OR, and pneumonia rates. The report emphasized the importance of adherence to the SSC. In 2011, a study was conducted to evaluate adherence to the SSC on various TJA procedures. The study found no significant adherence to the tool or verbal verification of the items on the list.

Utilization, compliance, and improved patient safety

Although it is difficult to demonstrate that preoperative and/or perioperative checklists directly impact patient safety, Mayer et al., and others have shown that checklists enhance individual team members’ attitudes toward safety. Checklists are proven to decrease communication errors and improve team compatibility, which together increase safety for patients. Moreover, checklists are associated with reduced risks of wrong-site surgery and better collaboration because of increased awareness of the surgical site. Jones et al., shared that preoperative checklists allowed their team to change the lineup order before the first case in the morning to avoid delays and to ensure that all safety considerations were addressed and limited. Using this system daily, their surgeons reported improved satisfaction, improved flow for the day, and increased surgeon satisfaction due to numerous factors, including fewer interruptions for questions during and between cases. At the same time, care must be taken to avoid blind repetition of the list without true validation of the items on the list. This is a potential danger we must all work hard to avoid for the SSC to work. The SSC also must be timely and meaningful.

Current checklist insufficient for orthopaedics

Procedures such as TJA remain without specialized communication tools that may prevent errors. For example, Thomasson et al., utilized the SSC in evaluating the prevention of orthopaedic error. Their assessment reported that the SSC failed to prevent orthopaedic equipment failures at their institution (Table 1). Researchers further concluded that although the SSC has potential to be an effective tool, it cannot be the only intervention in preparation for orthopaedic cases. Further studies are needed to assess the effects of various orthopaedic-specific checklists on patient safety.


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A large number of orthopaedic procedures are performed annually, allowing many opportunities for surgical complications and adverse events. Consequently, there is a need to utilize safety checklists for all invasive procedures. The number of complications may be further reduced by implementation and adherence to orthopaedic-specific safety checklists, together with effective teamwork. The current WHO SSC was not designed with the complexities of orthopaedic surgery in mind and therefore is not directly relevant. Now is the time to outline procedure-specific safety checklists for orthopaedics, especially with the growing challenges of a value-based healthcare environment.

Bilal Sleiman, BS, is a first-year student at the College of Human Medicine at Michigan State University.

Zain Sayeed, MD, MHA, is a postgraduate year (PGY)-1 in the Orthopaedic Surgery Residency Program at Detroit Medical Center and cofounder of Resident Research Partnership 501(c)(3).

Muhammad T. Padela, MD, MSc, is an orthopaedic clinical research fellow at Detroit Medical Center, cofounder of Resident Research Partnership 501(c)(3), and chief operating officer of FAJR Scientific 501(c)(3).

Walid K. Yassir, MD, MHCM, is chief of orthopaedic surgery at the Children’s Hospital of Michigan at Detroit Medical Center and serves on the Board of Directors of FAJR Scientific 501(c)(3).

Mark Zekaj, MD, is a PGY-4 in the Orthopaedic Surgery Residency Program at Detroit Medical Center.

Hussein F. Darwiche, MD, is chief of orthopaedic surgery at Harper University Hospital at Detroit Medical Center.

Khaled J. Saleh, MD, MSc, FRCS(C), MHCM, CPE, is on staff at the John D. Dingell VA Medical Center in Detroit and serves as chief executive officer of FAJR Scientific 501(c)(3) and Saleh Medical Innovations Consulting PLLC. He also holds a faculty appointment at the Michigan State University College of Osteopathic Medicine.

References:

  1. Panesar SS, Noble DJ, Mirza SB, et al: Can the surgical checklist reduce the risk of wrong site surgery in orthopaedics?–Can the checklist help? Supporting evidence from analysis of a national patient incident reporting system. J Orthop Surg Res 2011;6:18.
  2. Haynes AB, Weiser TG, Berry WR, et al: A surgical safety checklist to reduce morbidity and mortality in a global population. N Engl J Med 2009;360:491-9.
  3. de Vries EN, Prins HA, Crolla RMPH, et al: Effect of a comprehensive surgical safety system on patient outcomes. N Engl J Med 2010;363:1928-37.
  4. Boaz M, Bermant A, Ezri T, et al: Effect of Surgical Safety Checklist implementation on the occurrence of postoperative complications in orthopedic patients. Isr Med Assoc J 2014;16:20-5.
  5. Russ S, Rout S, Sevdalis N, et al: Do safety checklists improve teamwork and communication in the operating room? A systematic review. Ann Surg 2013;258:856-71.
  6. Sewell M, Adebibe M, Jayakumar P, et al: Use of the WHO surgical safety checklist in trauma and orthopaedic patients. Int Orthop 2011;35:897-901.
  7. Bergs J, Hellings J, Cleemput I, et al: Systematic review and meta-analysis of the effect of the World Health Organization Surgical Safety Checklist on postoperative complications. Br J Surg 2014;101:150-8.
  8. Mayer EK, Sevdalis N, Rout S, et al: Surgical checklist implementation project: the impact of variable WHO checklist compliance on risk-adjusted clinical outcomes after national implementation: a longitudinal study. Ann Surg 2016;263:58-63.
  9. Jones KC, Ritzman T: Perioperative safety: keeping our children safe in the operating room. Orthop Clin North Am 2018;49:465-76.
  10. Thomasson BG, Fuller D, Mansour J, et al: Efficacy of Surgical Safety Checklist: assessing orthopaedic surgical implant readiness. Healthc (Amst) 2016;4:307-11.

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