AAOS Now

Published 7/1/2010
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Howard R. Epps, MD

Building the case for checklists

Remaking the “to do” list for patient safety

The Checklist Manifesto: How to get things right by Atul Gawande, MD.

Metropolitan Books, Henry Holt and Company, LLC, New York, 2009, 209 pages. ISBN: 978-0-8050-9174-8

Many surgeons have noted a recent change in protocol at their hospitals from the relatively simple preoperative “time out” to the seemingly more burdensome World Health Organization (WHO) Surgical Safety Checklist. In his most recent contribution, The Checklist Manifesto: How to get things right, general surgeon and bestselling author Atul Gawande, MD, provides a fascinating description of the genesis, rationale, and evidence behind this most recent instrument designed to improve the safety and outcomes of surgical care.

Dr. Gawande, associate professor of surgery at Harvard Medical School and Harvard School of Public Health, also directs the WHO Surgical Safety Saves Lives initiative. As one deeply involved with the development and validation of the Surgical Safety Checklist, he argues that checklists should play a critical role in medical care, particularly as patient management becomes increasingly more complex, specialized, and technologically advanced. In today’s challenging medical environment, even the most highly trained and intelligent caregivers can make mistakes that can result in considerable morbidity and mortality.

Aviation checklists
The safety record of the aviation industry has been consistently envied by experts in medical safety, so Dr. Gawande starts his endorsement of checklists there. With several well-researched examples of airline near-disasters that were averted, he demonstrates how checklists are used in multiple situations to keep passengers safe. These examples also illustrate how the same principles can be extrapolated to medicine.

I had always questioned the validity of comparing medicine, where disease processes present in patients that are almost uniformly genotypically and phenotypically different, to an industry where each type of airplane is manufactured identically. Through multiple examples, however, the comparison grows more understandable.

Dr. Gawande builds his case for checklists with an example from the intensive care unit (ICU) at Johns Hopkins Hospital, where a simple five-item instrument checklist decreased the 10-day line infection rate from 11 percent to 0 percent. Applying the same principles in the state of Michigan, a project called the Keystone Initiative decreased ICU infections 66 percent, saving an estimated 1,500 lives and $175 million.

Checklists and communication
Dr. Gawande’s creativity as a surgeon and inherent inquisitiveness guide him to reveal the other critical component for improved safety—communication. Spending time with a structural engineer, he learned the vital role that checklists play in the construction of a building, where multiple systems must combine into a coherent structure that is functional and safe. In addition to a multitude of checklists, regularly scheduled communication occurs between the engineers of different areas to ensure that all the processes mesh seamlessly. More importantly, this mandatory communication allows the engineers to solve the obstacles that inevitably arise, as problems do in surgery.

His interest in checklists prompted visits to construction sites, flight simulators, and even the kitchen of a five-star restaurant. Convinced of the utility of checklists, he participated in an international panel of experts convened in Geneva by WHO to devise strategies to increase surgical safety. He observed that other colleagues shared his interest in checklists, some having already utilized early prototypes at their own institutions.

A checklist emerged from this meeting, but arduous testing and tweaking were necessary before it was ready for widespread use and validation. The final product was tested internationally in eight different hospitals in countries with tremendous variability in resources and levels of income. The astounding reduction in surgical mishaps resulted in an article published in The New England Journal of Medicine.

The validation of the checklist in such a broad range of hospital settings underscores its flexibility in adapting to different environments. The process of introducing each person and stating his or her role in the operating room prior to surgery seems absurd to people who work in small hospitals or surgical centers where surgeons frequently work with the same team. At a large teaching hospital where residents and employees are constantly changing, however, the value of this step becomes readily apparent.

Saving lives
Although Dr. Gawande practices endocrine surgery, he describes clinical scenarios that resonate regardless of specialty. One describes a patient with an innocuous-appearing stab wound, who rapidly deteriorated and almost expired from an aortic injury. The flaw in the doctor’s management was that nobody who evaluated the patient inquired what type of weapon caused the injury—a misstep Dr. Gawande argues a checklist would have avoided. But whether knowing the type of weapon used would have caused the team to manage the case differently can be debated.

The book ends, however, with an example of one of Dr. Gawande’s own patients who almost died from an intraoperative complication. The role checklists played in this patient’s ultimate survival is much more convincing. More importantly, the example illustrates how the routine use of checklists—no matter how mundane the situation—can make a tremendous difference for patients.

Presented with the impressive effects a relatively simple checklist had on patient safety, Dr. Gawande ponders whether similar specialty- and procedure-specific lists could improve outcomes in common operations such as hip arthroplasty and knee arthroscopy. One wonders whether checklists can gain enough acceptance that a surgeon performing a less familiar procedure could feel comfortable bringing a list of the operation’s steps to the surgical suite without losing the confidence of the staff in the room.

For those with an interest in patient safety and quality in surgical care, The Checklist Manifesto is mandatory reading. Dr. Gawande’s lucid, engaging style should make the book accessible and relevant to the lay reader as well. Fans of his previous bestsellers Complications: A Surgeon’s Notes on an Imperfect Science and Better: A Surgeon’s Notes on Performance will find this most recent effort equally compelling. The chief of surgery at Children’s Hospital of Philadelphia has provided every surgeon on staff with a copy gratis.

Skeptics who question the value of the additional hurdles they must jump before starting routine surgical cases should consider reading the book as well. A greater understanding of the thought processes, research, and evidence that produced the WHO Surgical Safety Checklist could transform the checklist from an imposed annoyance to a valuable tool to improve surgical outcomes.

Howard R. Epps, MD, is a member of the AAOS Now editorial board. He can be reached at epps@fondren.com

Additional Link:
WHO Surgical Safety Checklist