An interview with pediatric orthopaedic surgeon, James R. Kasser, MD

As surgeon-in-chief at Children’s Hospital Boston, James R. Kasser, MD, has championed the use of safe surgery checklists for years. Recently, he spoke with AAOS Now editorial board member John M. Purvis, MD, about his efforts to make safe surgery checklists “standard operating procedure” at Children’s Hospital Boston.

AAOS Now: Dr. Kasser, when did you institute the use of checklists for surgical cases?

Dr. Kasser: Surgical checklists became part of the operating room (OR) routine at Children’s Hospital Boston approximately 2½ years ago. Given the priorities of all the varied individuals in the OR environment, this was not a simple feat, as I am sure you are aware. Nurses, anesthesiologists, and surgeons are focused on performing specific tasks to achieve perfection in their respective areas of responsibility. Using a checklist to coordinate efforts to function as a team before the surgery starts can help prevent errors and improve care and efficiency.

AAOS Now: How did you become aware of the value of the checklists?

Dr. Kasser: The value of a preoperative surgical checklist was made apparent by an article published in The New England Journal of Medicine, attesting to the benefits in all hospitals of a surgical checklist promoted by the World Health Organization (WHO). Although clear evidence of the benefits of using the checklist can be found, incorporation in individual hospitals has often met with resistance.

AAOS Now: How did Children’s Hospital Boston develop and implement the checklist?

Dr. Kasser: I serve as the surgeon-in-chief and chairman of the OR Governance Committee at Children’s Hospital Boston. Our committee is responsible for managing the OR and establishing the rules and policies that govern the OR environment. Following the publication of the WHO checklist, we thought a checklist would improve the safety of our OR environment and decided to make its use mandatory.

It’s not always easy to bridge the gap between establishing a policy and achieving compliance in practice. We pursued a specific program for inclusion of a checklist in the surgical routine. One member from each department served as the lead in establishing the OR checklist pilot program. We solicited feedback from each of these individuals on specific problems each department might encounter in incorporating the checklist. We made some small changes to adapt the checklist to a children’s hospital environment, but its substance remained the same.

Wall charts of the checklist (Fig. 1) were placed in each OR. The WHO checklists include a “sign-in,” a “time-out,” and a “sign-out.” The sign-in checklist—including the signing of the surgical site by the surgeon—must be completed prior to entering the OR.

The time-out checklist is done after prepping and draping but before the initiation of surgery. The introduction of team members is critical to establishing the interdependent, cooperative environment in the OR and to breaking down hierarchal barriers to effective communication. Other aspects of the time-out include confirmation of prophylactic antibiotics, specific planning for the procedure, review of imaging, and comment on specific medical or surgical issues pertaining to each patient. The sign-out confirms that the surgical procedure planned was done properly and summarizes critical aspects of postoperative management.

AAOS Now: How have the checklists been received by surgeons, residents, and OR staff?

Dr. Kasser: Compliance with the “sign-in” checklist process in our operating environment is 100 percent. The “time-out” at the beginning of the case has become part of the fabric of the OR and has been accepted by all members of the surgical team, such that no one would think of proceeding with a case without a formal time-out. It is critical that the time-out follow the checklist rather than simply pause so an individual can confirm the surgery to be performed. Within the first 6 months, we attained a time-out compliance rate of 95 percent to 98 percent for all services. Today, our time-out compliance is 99 percent.

It was much more difficult to achieve compliance with the sign-out. Depending on the service, the compliance rate was just 50 percent to 78 percent. Although the reason for failure to comply with sign-out was not clear, I believe it related to the absence of a clear point when all participants must focus their attention on the checklist. This, however, has recently changed.

AAOS Now: Over time, have you had to make modifications in your checklist or protocol?

Dr. Kasser: Six months ago, following a thoracic surgery, a retained sponge was found on a routine postoperative chest X-ray. Although this should never happen, such events actually occur in the United States at a rate of one for every 1,000 to 10,000 surgeries. We viewed a retained foreign object as a “never event” and sharpened our processes to eliminate this error. We added the “closing time- out” to the surgical checklist and set a goal of 100 percent compliance with the closing time-out and the sign-out.

As we reviewed the behavior that led to the error we noted that the OR team was not focusing attention on the patient at the time of closing, ensuring that all sponges and equipment were accounted for. Through this checklist modification, we mandated that the surgeon explores the wound, the nurses count the sponges accurately with surgical team involvement, and anesthesia personnel participate in the process. Our most recent audit found that compliance with the closing time-out and sign-out now is at 99 percent.

AAOS Now: Is using checklists the right thing to do?

Dr. Kasser: I believe that the incorporation of the WHO checklist in its slightly modified state at Children’s Hospital Boston has resulted in a safer environment with improved teamwork. It focuses the team at specific points through a routine sequence of questions that document specific but critical facts necessary for surgical success. The introduction of a checklist into the OR environment can be accomplished with the commitment of OR management, surgeons, anesthesiologists, and nursing staff. A few moments spent checking facts and establishing an environment of teamwork yields significant benefits in any OR.

John M. Purvis, MD, sits on the AAOS Now editorial board.

Additional Resources:
A Surgical Safety Checklist to Reduce Morbidity and Mortality in a Global Population
World Health Organization Safe Surgery Saves Lives