Communication is considered a vital part of safe health care for our clients and patients. Checklists have become part of standard practice in both the intensive care unit and throughout the surgical journey of a patient.
The amazing breakthrough of checklists started in 2001 with Dr. Peter Pronovost, a critical care specialist at Johns Hopkins Hospital, who through the development of checklists was able to reduce the incidence of pneumonia in surgical patients by a quarter, resulting in 21 fewer patient deaths than in the previous year.
The success of his work started to gain a lot attention worldwide, and Ontario, Saskatchewan, Alberta and British Columbia now mandate the Checklist be used in every surgery.
Can we improve our care in the operating room? You bet we can. Here are some statistics to summarize what our current reality might look like. Worldwide, approximately 11% of illness is due to diseases that are surgically treatable1, resulting in the performance of an estimated 234 million surgical procedures annually.2
Studies in industrialized countries show that the perioperative death rate for inpatient surgery is 0.4% to 0.8%, and the rate of major complications varies from 3% to 17%.3,4
During the 2007/2008 fiscal year, 119,926 inpatient surgical procedures were performed in BC. Applying the Baker and Norton3 findings to surgical care in BC, and assuming a 7.5% adverse event rate, 8,995 surgical inpatient cases with at least one adverse event would have occurred. Of these, 3,319 (36.9%) would have had at least one preventable adverse event, and 589 to 920 cases would have resulted in preventable deaths.
Three Key Things
The Checklist is a tool that can assist with three key things that are important to the surgical patient:
- Improving teamwork and communication
- Increasing efficiency
- Reducing complications
It is increasingly clear that improvements in health care will depend progressively more on our ability to promote excellent teamwork and effective communication across the spectrum of clinical care. In root-cause analysis of more than 4,000 adverse events, the Joint Commission identified communication breakdown as the most common factor and made improving the effectiveness of communication among caregivers a patient safety goal for 2008.5
Halverson et al.6 (2010) examined communication failures in the OR and found that the most common failures related to equipment and keeping team members updated as to the progress of an operation. Both Halverson and Nundy7 (2008) found that these failures can lead to procedural delay and inefficiencies and that checklists can reduce delays by 31%.
The most recent breakthrough in using a checklist in a surgery environment is a study from the Netherlands a simple multidisciplinary checklist for the entire surgical continuum showed a decrease in complications from 15.4% to 10.6% and a decrease for in-hospital mortality from 1.5% to 0.8%8.
Many operating room teams might respond with these questions
- We already do these things. Why should we use a checklist?
- We are functioning well as a team. Do we need another thing to do?
- The team is very capable. As a surgeon, why do I have to be present for the briefing element of the Checklist?
Inevitably, this is how some teams might initially react to the Checklist. Implementing this tool has not been as easy as initially thought. Even though the Checklist itself only takes 2-3 minutes to complete, the surgeon (or representative) needs to reorganize his/her workday and flow in order to be in the operating room before the patient is induced in order to attend the briefing element. This has been one of the hardest things for teams to adjust.
Many teams work well together, but most of the literature suggests that there is a significant discrepancy between disciplines when asked to rate the quality of teamwork in the OR.
Makary et al9 (2006) found that physicians rated the teamwork of others as good; but at the same time, nurses perceived team work as mediocre. The Veterans Affairs system certainly showed us that investment in teamwork and communication paid off. O’Neilly et al10 (2010) found that they reduced mortality by 18% percent after the implementation of on-site training in teamwork, communications and surgeon coaching across 208 hospitals. Mazzocco11 et al also found a correlation between positive teamwork behaviour and better patient outcomes.
It is becoming clear that when teams exhibited infrequent team behaviours, patients are more likely to experience death or major complication.
At a Glance
BC Patient Safety & Quality Council
Marlies van Dijk,
Director of Clinical Improvement
BC Patient Safety & Quality Council
Director, Clinical Consultation and Guidelines
Health Services Policy and Quality Assurance Division
Ministry of Health