Modified Surgical Safety Checklists Decrease Adverse Outcomes

Most global and regional initiatives that address surgical safety advise the use of checklists adapted to sites’ unique needs. The initiatives generally identify 3 stages where checklists are needed: before anesthesia induction, before incision, and before the patient leaves the operating room.

The impetus for this movement toward checklists involved several observational studies that demonstrated striking improvements in surgical outcomes when checklists were used properly and routinely. In many areas, surgical checklists have become mandatory.

Researchers in Ontario, Canada — a region where recent policy changes encourage hospitals to adopt checklists — used the shift in policy and pending procedural adjustments to assess checklists’ effectiveness in typical practice settings among 3 surgeons. The results of their study were published in the March 2014 issue of Lancet with an accompanying editorial.

For the study, the researchers first identified appropriate outcomes, including operative mortality, surgical complication rate, length of hospital stay, emergency department visits within 30 days after discharge, and hospital readmission rate. Using administrative health data, they compared patients who had surgical procedures at 101 hospitals before and after checklist adoption.

During the 3-month period before adopting a surgical safety checklist, surgeons performed 109,341 procedures, while in the 3-month period following checklist adoption, they performed 106,370 procedures. The authors found no significant differences in key outcomes after the checklist was implemented, as the adjusted risk of surgical complications was 3.86% before implementation and 3.82% afterwards. Thus, the researchers concluded the implementation of surgical safety checklists in Ontario, Canada, did not reduce operative mortality or complications significantly.

Ninety percent of the Ontario hospitals employed unmodified World Health Organization (WHO) or Canadian Patient Safety Institute (CPSI) checklists. The study’s accompanying editorial suggested hospitals that modified those checklists would have better outcomes, though it noted full checklist implementation is difficult because typical operating rooms do not perform many of the tasks included in preformatted checklists.

The editorial further stressed “it is not the act of ticking off a checklist that reduces complications, but performance of the actions it calls for.” Although compliance with checklists may be low and many surgeons check off boxes rapidly and thoughtlessly, the editorial concluded checklists that are used consistently decrease adverse surgical outcomes over time.