Reducing Surgical Complications – The Checklist

Hospitals are not safe places – that’s a fact and is also a fact that, despite substantial efforts over the past few years, hospitals remain unsafe. It is estimated that 1 of every 150 patients admitted to the hospital dies as a result of a preventable medical error. Since over 50% of errors are associated with surgery, it is logical that extensive efforts should be placed there.

Hospitals are not safe places – that’s a fact and is also a fact that, despite substantial efforts over the past few years, hospitals remain unsafe. It is estimated that 1 of every 150 patients admitted to the hospital dies as a result of a preventable medical error. Since over 50% of errors are associated with surgery, it is logical that extensive efforts should be placed there.

Checklists have proven useful. A WHO study of an OR checklist at eight hospitals worldwide found a reduction of major complications from 11% to 7% after checklists were introduced. But many have challenged these results.

A new study, with appropriate controls, was reported from the Netherlands in the New England of Medicine on Nov 11, 2010. It looked at a checklist that spanned the entire surgical pathway – admission to discharge. Participant hospitals spent about 6 to 9 months implementing the checklist. The evaluations spanned 3 months before and 3 months after implementation at two academic medical centers and four teaching hospitals. A separate control evaluation was done during two three month periods at a different academic medical center and at four other teaching hospitals.

3760 patients who received 4364 procedures made up the pre-implementation sample and 3820 patients (4387 procedures) were the post-implementation study group. When a random sample of checklists was evaluated, a median of 80% of the items were completed – with substantial variation between and within individual hospitals.

Complications declined from 27.3 per 100 patients (Wow! This just goes to show that errors are frequent; much more frequent that most want to accept or admit) to 16.7/ 100 patients (A great reduction but still a disturbingly high rate of complications even after checklist implementation.) Stated differently, 15.4% of pre-implementation patients had one or ore complications; this declined to 10.6% post implementation (Again, a good reduction but still leaves lots of room for further improvements.)

Patients with checklist completion above the 80% median had fewer complications (7.1/100 patients) then those below the median (18.8/100 patients.) This again signals the value of the checklist and following the defined procedure thoroughly and carefully.

Among these surgical patients, hospital deaths declined by about one half, from 1.5% t to 0.8%.

At the control hospitals, the rate of complications remained stable at about 30-31/ 100 patients.

The study clearly defines the value of completing the checklist – and dong so completely. It also makes clear that the checklist needs to follow the entire surgical pathway and that it needs to be completed in full for optimal results.

The checklist is comprehensive and therefore takes time – of surgeon, anesthiologist, nurse and others. To be effective, hospitals will need to adjust work loads and work schedules to accommodate these requirements while concurrently requiring compliance.

But even this checklist, followed intensively and explicitly, is not enough. This study was impressive for its reduction in complications and deaths but it also was impressive in demonstrating that the hospital is fundamentally an unsafe place for (surgical) patients. There is still much to do.

Hospital boards need to be more involved, vigilant and more insistent that complications rates be reduce to zero. That must be the goal. When the board insists that safety is paramount, the hospital management will put in the time, effort and the change of culture that is needed. Sooner or later, patients will figure out where they should go for (surgical) care that will be accompanied by the least chance of harm. When that happens, the less safe hospitals will have fewer patients and reduced revenues; for sure the board and management will notice then but it may be too late.

Stephen Schimpff, MD is retired CEO of the University of Maryland Medicine Center, a professor of medicine and public policy and author of “The Future of Medicine – Megatrends in Healthcare.”

Submitted April 12, 2011