Checklists are everywhere: packing for a trip (I don’t want to forget my running shoes!); going to grocery store (let’s see… arugula, peanut butter, olive oil); planning the day (return library books – check! laundry – check! pay bills – hmm, maybe later).
These examples are fairly humdrum but, in anesthesia and surgery, the use of checklists can have a tremendously positive impact. The World Health Organization (WHO) introduced the Surgical Safety Checklist (SSC) in 2008 and, over the past decade, its use has spread around the globe, in low and high resource settings, and beyond the operating theater. When introduced and applied correctly, anesthesia and surgical safety checklists save lives.
As a veterinary anesthesiologist, my goals are to facilitate the required procedure while providing the best patient experience and outcome possible. These - sometimes dueling - interests often necessitate prioritization, working with divided attention, and maintaining “situational awareness”. The thing is, no matter how conscientious, highly trained, and dedicated I am – no matter how hard I try - I will still make mistakes, especially in times of stress. Checklists are one of the tools I use to safely accomplish my clinical tasks and reduce the chance of error.
Checklists are cognitive aids that delineate and categorize essential steps, providing structure in the face of complexity. They ensure implementation of required processes and reduce ambiguity about what must be done. Checklists can reduce the potential for error that exists solely because anesthesiologists and surgeons and nurses are humans. Human error is inevitable and checklists can help catch those errors before they have clinical consequences. They let us get out of our own way and make sure we do the little things that - though central to the overall process - can be easy to dismiss, or delay and then forget.
But a correctly applied checklist does more than just catch the “little” things (Were antibiotics given before incision? Has the path sample been collected and labeled?), when performed properly, checklists improve communication, flatten hierarchy, and turn a random group of people into a team who have all the necessary information to achieve their clinical goals.
Anesthesia and surgical checklists are completed as a group exercise during 3 pauses in anesthesia care: before induction, before incision, and before leaving the OR. The entire healthcare team stops what they are doing and, for 30 – 60 seconds, has a formalized conversation about what has been done and what the plan is going forward. Everyone in the room is on the same page, everyone has the same information, and everyone knows what needs to happen next.
Checklists are familiar to anesthesiologists as they have long been used to mitigate the complications introduced by the use of anesthetic equipment. In fact in one study – almost 4 decades ago – it was determined that the commonest factor in anesthetic mishaps was the failure to perform the anesthetic equipment checklist prior to induction. (1)
Checklists were adapted from the aviation industry, which has been using them as a matter of course since the late 1930s. The first widely adopted medical checklist surrounded the placement of central venous catheters.(2) Like all good checklists, it focused on ensuring that evidenced-based processes were actually followed and included very basic things like: “Are the physician’s hand clean?”In addition to the checklist, a variety of other interventions (e.g. staff education & empowering nurses to stop catheter placement if guidelines were not followed) were also included. Implemented first in a couple of ICUs at Johns Hopkins, and then across Michigan, the central line checklist and the resulting culture shift were shown to reduce central line associated blood stream infections and reduce hospital deaths.(3)
Following the success of this checklist implementation, the WHO underwrote a prospective before- and after- intervention study, published in the New England Journal of Medicine in 2009, trialing the Surgical Safety Checklist in 8 hospitals of varying economic circumstances around the globe. Importantly, the SSC wasn’t just thrown at the medical teams without explanation. There was a formalized introduction process that included staff training, engagement of local leaders, and a system for ongoing contact and encouragement.
The results of this study were quite positive: mortality and postoperative complications in surgical patients were reduced by about 40% each, with a slightly bigger effect in low income versus high income hospitals. The rates of surgical site infection and unplanned return to the OR also decreased significantly.(4) In addition, compliance with established standards of care improved by 65%, meaning these hospitals were doing a better job at doing what they were already supposed to be doing.
Investigation into the use of checklists in veterinary anesthesia and surgery has been positive as well. When implemented with care, checklists have decreased major and minor perioperative complications and improved standards compliance.(5 – 8)
Checklists are really exciting to me. They are a cheap, accessible intervention that measurably improves the quality of anesthesia care. We aren’t talking about buying a fancy anesthesia monitor or hiring more staff (though maybe these things are a good idea too!). This is a quality improvement tool that costs only the time and effort it takes to implement it.
The WHO SSC is freely available on line: https://www.who.int/patientsafety/safesurgery/checklist/en/
Ariadne Labs has a variety of tools available for downloading, including resrouces for developing and implementing your own checklists. You have to register with them but it is free to do so: http://www.ariadnelabs.org/resources/downloads/
And the Association of Veterinary Anaesthetists has checklist and anesthesia monitoring forms here: https://ava.eu.com/resources/checklists/
A checklist should be tailored to your specific clinical environment. You want to make it succinct with easy-to-read font, non-repetitive, able to be completed in about 45 seconds, and focused on patient safety.
Importantly, when you decide to introduce checklists to your clinical environment, engage all stakeholders - nurses, doctors, assistants - in the discussion; make sure everyone understands what they are supposed to do and WHY they are doing it. If you impose a checklist without explanation, it will be seen as just that: an imposition. Without comprehensive training and follow-up, the checklist may not be used or used appropriately.(9)
Finally, check in regularly with the team for feedback on what’s working and what may need to be changed. Realize that checklists are not a panacea for a broken safety culture but they can be a catalyst for anesthesia quality improvement.
The bottom line is that checklists save lives because a lack of teamwork & poor communication are the cause of many preventable errors.
Do you use anesthesia safety checklists in your clinic?
Have you tried to introduce them and met with resistance?
Would you want the SSC used on you or your loved one?
Let us know what you think about checklists!
References:
1. Craig J, Wilson ME. A survey of anaesthetic misadventures. Anaesthesia. 1981 Oct;36(10):933-6.
2. Berenholtz SM, Pronovost PJ, Lipsett PA,et al. Eliminating catheter-related bloodstream infections in the intensive care unit. Crit Care Med. 2004 Oct;32(10):2014-20.
3. Pronovost P. Interventions to decrease catheter-related bloodstream infections in the ICU: the Keystone Intensive Care Unit Project. Am J Infect Control. 2008 Dec;36(10):S171.e1-5.
4. 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 Jan 29;360(5):491-9.
5. Hofmeister EH, Quandt J, Braun C, Shepard M. Development, implementation and impact of simple patient safety interventions in a university teaching hospital. Vet Anaesth Analg. 2014 May;41(3):243-8.
6. Ward J, McLaughlin A, Burzette R, et al. The effect of a surgical safety checklist on complication rates associated with permanent transvenous pacemaker implantation in dogs. J Vet Cardiol. 2018 Dec 5. pii: S1760-2734(18)30104-8.
7. Bergström A, Dimopoulou M, Eldh M. Reduction of Surgical Complications in Dogs and Cats by the Use of a Surgical Safety Checklist. Vet Surg. 2016 Jul;45(5):571-6.
8. Cray MT, Selmic LE, McConnell BM, et al. Effect of implementation of a surgical safety checklist on perioperative and postoperative complications at an academic institution in North America. Vet Surg. 2018 Nov;47(8):1052-1065.
9. Menoud G, Axiak Flammer S, Spadavecchia C, et al. Development and Implementation of a Perianesthetic Safety Checklist in a Veterinary University Small Animal Teaching Hospital.Front Vet Sci. 2018 Apr 3;5:60.