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The Surgical Checklist: It Cannot Work If You Do Not Use It

The Surgical Checklist: It Cannot Work If You Do Not Use It Surgical safety checklists (SSCs) are associated with reductions in postoperative morbidity and mortality and have now achieved widespread implementation, although the quality of implementation remains unclear in many settings.1,2 In this issue of JAMA Surgery, Bock and colleagues3 evaluate the effect of introducing an SSC in a single Italian referral hospital on 30- and 90-day all-cause mortality, 30-day readmission rate, and hospital length of stay. Bock et al3 demonstrate a statistically significant decrease in overall surgical mortality at 90 days after surgery and a reduction in hospital length of stay after implementation of an SSC. Most previous publications that examined surgical mortality focused on the more traditional and widely accepted 30-day postoperative mortality and readmission rates. Historically, the 30-day outcomes were chosen because of difficulties with long-term follow-up and issues with attributing death in the 30- to 90-day postoperative period to the primary surgical procedure.3 We commend the authors for choosing to focus on the 90-day postoperative all-cause mortality rate, and we are reassured that they saw a statistically significant decrease. However, we should also consider why no statistically significant change in the 30-day postoperative all-cause mortality rates was observed. This finding could be attributable to inherent differences in the population studied, to the case mix, or to insufficient power to detect change related to sample size. This article also highlights the ongoing challenges of checklist implementation and measurement of the impact of the SSC. First, whether SSC performance underwent direct observation during implementation and whether that observation compared with reported performance are unclear. Checklist performance appears to be measured primarily by checking whether a form was completed. Significant discordance between paper checklist completion and actual completion has been described.4 Second, 80% completion was considered the threshold for complete implementation in this study, whereas recent literature supports that full rather than partial checklist completion provides an opportunity for significant improvement of the effect of the SSC on the quality of patient care and surgical safety.5 With more effective implementation and full SSC use in every case, the improvement in outcomes seen could have been even. If the SSC is not used, it cannot help. Although some investigators question the actual impact of checklists, despite the proliferation of evidence regarding improved patient outcomes and quality of care across countries, these arguments fail to acknowledge fully the difficulty of effectively implementing SSCs in a complex health system.6 A focus on the systems of care and promotion of a culture of safety at the institutional level is necessary to optimize checklist implementation and realize its full potential. Effective implementation is critical to meaningful use of SSCs, which can lead to maximally improved outcomes. Back to top Article Information Corresponding Author: William Berry, MD, MPH, Department of Health Policy and Management, Harvard School of Public Health, 677 Huntington Ave, Boston, MA 02115 (wberry@ariadnelabs.org). Published Online: February 3, 2016. doi:10.1001/jamasurg.2015.5551. Conflict of Interest Disclosures: None reported. References 1. Haynes AB, Weiser TG, Berry WR, et al; Safe Surgery Saves Lives Study Group. A surgical safety checklist to reduce morbidity and mortality in a global population. N Engl J Med. 2009;360(5):491-499.PubMedGoogle ScholarCrossref 2. de Vries EN, Prins HA, Crolla RM, et al; SURPASS Collaborative Group. Effect of a comprehensive surgical safety system on patient outcomes. N Engl J Med. 2010;363(20):1928-1937.PubMedGoogle ScholarCrossref 3. Bock M, Fanolla A, Segur-Cabanac I, et al. A comparative effectiveness analysis of the implementation of surgical safety checklists in a tertiary care hospital [published online February 3, 2016]. JAMA Surg. doi:10.1001/jamasurg.2015.5490.Google Scholar 4. O’Connor P, Reddin C, O’Sullivan M, O’Duffy F, Keogh I. Surgical checklists: the human factor. Patient Saf Surg. 2013;7(1):14.PubMedGoogle ScholarCrossref 5. Mayer EK, Sevdalis N, Rout S, et al. Surgical checklist implementation project: the impact of variable WHO checklist compliance on risk-adjusted clinical outcomes after national implementation: a longitudinal study. Ann Surg. 2016;263(1):58-63.Google ScholarCrossref 6. Gagliardi AR, Straus SE, Shojania KG, Urbach DR. Multiple interacting factors influence adherence, and outcomes associated with surgical safety checklists: a qualitative study. PLoS One. 2014;9(9):e108585.PubMedGoogle ScholarCrossref http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png JAMA Surgery American Medical Association

The Surgical Checklist: It Cannot Work If You Do Not Use It

JAMA Surgery , Volume 151 (7) – Jul 1, 2016

The Surgical Checklist: It Cannot Work If You Do Not Use It

Abstract

Surgical safety checklists (SSCs) are associated with reductions in postoperative morbidity and mortality and have now achieved widespread implementation, although the quality of implementation remains unclear in many settings.1,2 In this issue of JAMA Surgery, Bock and colleagues3 evaluate the effect of introducing an SSC in a single Italian referral hospital on 30- and 90-day all-cause mortality, 30-day readmission rate, and hospital length of stay. Bock et al3 demonstrate a statistically...
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Publisher
American Medical Association
Copyright
Copyright © 2016 American Medical Association. All Rights Reserved.
ISSN
2168-6254
eISSN
2168-6262
DOI
10.1001/jamasurg.2015.5551
Publisher site
See Article on Publisher Site

Abstract

Surgical safety checklists (SSCs) are associated with reductions in postoperative morbidity and mortality and have now achieved widespread implementation, although the quality of implementation remains unclear in many settings.1,2 In this issue of JAMA Surgery, Bock and colleagues3 evaluate the effect of introducing an SSC in a single Italian referral hospital on 30- and 90-day all-cause mortality, 30-day readmission rate, and hospital length of stay. Bock et al3 demonstrate a statistically significant decrease in overall surgical mortality at 90 days after surgery and a reduction in hospital length of stay after implementation of an SSC. Most previous publications that examined surgical mortality focused on the more traditional and widely accepted 30-day postoperative mortality and readmission rates. Historically, the 30-day outcomes were chosen because of difficulties with long-term follow-up and issues with attributing death in the 30- to 90-day postoperative period to the primary surgical procedure.3 We commend the authors for choosing to focus on the 90-day postoperative all-cause mortality rate, and we are reassured that they saw a statistically significant decrease. However, we should also consider why no statistically significant change in the 30-day postoperative all-cause mortality rates was observed. This finding could be attributable to inherent differences in the population studied, to the case mix, or to insufficient power to detect change related to sample size. This article also highlights the ongoing challenges of checklist implementation and measurement of the impact of the SSC. First, whether SSC performance underwent direct observation during implementation and whether that observation compared with reported performance are unclear. Checklist performance appears to be measured primarily by checking whether a form was completed. Significant discordance between paper checklist completion and actual completion has been described.4 Second, 80% completion was considered the threshold for complete implementation in this study, whereas recent literature supports that full rather than partial checklist completion provides an opportunity for significant improvement of the effect of the SSC on the quality of patient care and surgical safety.5 With more effective implementation and full SSC use in every case, the improvement in outcomes seen could have been even. If the SSC is not used, it cannot help. Although some investigators question the actual impact of checklists, despite the proliferation of evidence regarding improved patient outcomes and quality of care across countries, these arguments fail to acknowledge fully the difficulty of effectively implementing SSCs in a complex health system.6 A focus on the systems of care and promotion of a culture of safety at the institutional level is necessary to optimize checklist implementation and realize its full potential. Effective implementation is critical to meaningful use of SSCs, which can lead to maximally improved outcomes. Back to top Article Information Corresponding Author: William Berry, MD, MPH, Department of Health Policy and Management, Harvard School of Public Health, 677 Huntington Ave, Boston, MA 02115 (wberry@ariadnelabs.org). Published Online: February 3, 2016. doi:10.1001/jamasurg.2015.5551. Conflict of Interest Disclosures: None reported. References 1. Haynes AB, Weiser TG, Berry WR, et al; Safe Surgery Saves Lives Study Group. A surgical safety checklist to reduce morbidity and mortality in a global population. N Engl J Med. 2009;360(5):491-499.PubMedGoogle ScholarCrossref 2. de Vries EN, Prins HA, Crolla RM, et al; SURPASS Collaborative Group. Effect of a comprehensive surgical safety system on patient outcomes. N Engl J Med. 2010;363(20):1928-1937.PubMedGoogle ScholarCrossref 3. Bock M, Fanolla A, Segur-Cabanac I, et al. A comparative effectiveness analysis of the implementation of surgical safety checklists in a tertiary care hospital [published online February 3, 2016]. JAMA Surg. doi:10.1001/jamasurg.2015.5490.Google Scholar 4. O’Connor P, Reddin C, O’Sullivan M, O’Duffy F, Keogh I. Surgical checklists: the human factor. Patient Saf Surg. 2013;7(1):14.PubMedGoogle ScholarCrossref 5. Mayer EK, Sevdalis N, Rout S, et al. Surgical checklist implementation project: the impact of variable WHO checklist compliance on risk-adjusted clinical outcomes after national implementation: a longitudinal study. Ann Surg. 2016;263(1):58-63.Google ScholarCrossref 6. Gagliardi AR, Straus SE, Shojania KG, Urbach DR. Multiple interacting factors influence adherence, and outcomes associated with surgical safety checklists: a qualitative study. PLoS One. 2014;9(9):e108585.PubMedGoogle ScholarCrossref

Journal

JAMA SurgeryAmerican Medical Association

Published: Jul 1, 2016

Keywords: guideline adherence,surgical checklist

References