Surgical Safety Checklist Drops Deaths and Complications

An international pilot study involving the Toronto General Hospital (TGH), a teaching hospital affiliated with the University of Toronto, has found that using a surgical patient safety checklist significantly reduces surgical complications and mortality. The study, led by the World Health Organization (WHO) and Atul Gawande, MD of the Harvard School of Public Health, appears in the New England Journal of Medicine.

“We know that many surgical complications are preventable,” Bryce Taylor, MD, University Health Network’s surgeon in chief, who co-authored the study for TGH said in a news release. “With approximately 234 million surgeries performed each year worldwide, we owe it to our patients to look at every opportunity to prevent complications during and after surgery.”

The Checklist is intended to improve communications among members of the surgical team.
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Studies in industrialized countries have found that major complications occur in 3% to 16% of inpatient surgeries and perioperative death rates for inpatient surgery of 0.4% to 0.8%. Inconsistent approaches to surgery can also lead to adverse events. For example, there is strong evidence to support using antibiotics within one hour prior to incision as a prophylaxis to reduce the possibility of wound infections. Yet, surgical teams around the world are inconsistent in their approaches.

Launched in October 2007, TGH and seven hospitals located in cities around the world were selected by the WHO and Harvard to pilot a surgical patient safety checklist as part of the WHO’s “Safe Surgery Saves Lives” initiative. Developed by an international group made up of leading surgeons, nurses, anesthesiologists and patient safety experts, the WHO checklist was influenced by checklists used in the airline industry to reduce the incidence of airline errors.

The checklist is intended to improve communications among members of the surgical team during surgery and to increase the consistency in using proven standards of surgical care. A member of the surgical team verbally confirms the completion of each step at three critical points during surgery. Those points are prior to anesthesia, immediately prior to incision and prior to patient exiting the operating room, for infection prophylaxis, anesthesia safety and other essential steps in surgery. This would include confirming that the surgery site has been marked and counting the number of sponges and instruments used at the end of surgery to ensure nothing has been left inside of the patient.

Each pilot site implemented the checklist in their operating rooms and tracked changes in the rate of inpatient complication or death within 30 days of surgery. To establish a baseline, data was collected from a total of 3,733 patients before the implementation of the checklist and 3,955 patients after it was introduced.

Using the checklist, the study found the rate of major complication in the study operating rooms fell from 11% in the baseline period to 7% after the introduction of the checklist. Inpatient deaths following operation fell by over 40% (from 1.5% to 0.8%).

Similar reductions in complications were seen in both the high income and lower income sites in the study, with rates falling from 10.3% to 7.1% and 11.7% to 6.8% respectively.

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