Surgical Checklist From WHO Improves Safety and Outcomes

Emma Hitt, PhD

November 11, 2012

The World Health Organization (WHO) Surgical Safety Checklist appears to improve safety and patient outcomes when adhered to in the operating room, according to an analysis of 20 studies.

Axel Fudickar, MD, from the Department of Anesthesiology and Intensive Care Medicine, University Medical Center Schleswig-Holstein, Kiel, Germany, and colleagues report their findings in an article published in the November issue of Deutsches &Aumlaut;rzteblatt International.

In 2009, WHO issued a worldwide recommendation for the use of its Surgical Safety Checklist in all operative procedures.

"A team that has had some practice in the use of the checklist can complete all three parts of it in about two minutes," the authors note.

The current report reviews the "available data on the implementation of this checklist and its effect on perioperative morbidity and mortality and on operating-room safety culture," the authors write. The researchers also surveyed experience with the checklist and provide recommendations for its practical implementation.

Dr. Fudickar and colleagues reviewed studies published before February 2012 in the PubMed and Medline databases using the search term "surgical safety checklist."

A total of 20 studies were included in the analysis. One surgical outcome study indicated a decrease of 47% in perioperative mortality, from 56 deaths in 3733 cases (1.5%) to 32 deaths in 3955 cases (0.8%). A second study showed a decrease of 62%, from 31 deaths in 842 cases (3.7%) to 13 deaths in 908 cases (1.4%). These 2 studies also showed a more than a one third decrease in perioperative morbidity outcomes.

The researchers also found improved interdisciplinary communication, using procedures such as relaying information out loud and introducing oneself by name before the start of surgery, to improve patient safety.

Several factors facilitated the use of the checklist, including exemplary implementation by team leaders and structured training, the authors note.

"Typical errors in implementation are lack of completeness and processing in the absence of team members," the authors note. "It is also wrong for a single person to go through all of the items on the list without communicating their content to others or providing any opportunity for an exchange of information."

In a related editorial, Alexandra Busemann, MD, from the Universitäts-medizin Greifswald, in Germany, and Claus-Dieter Heidecke, MD, PhD, from the German Society of Surgery, noted that "[t]he authors' encouraging findings ought to motivate the universal adoption of this new, beneficial instrument."

In contrast, they point out that used as is, the WHO list might be an "inadequate safeguard against common perioperative errors," because patients "are often not cared for by the same physician throughout."

They add that "[t]hese processes would clearly be better if the surgeon who will actually perform the operation sees the patient personally beforehand and confirms the indication for surgery."

In an independent comment to Medscape Medical News, Mustafa Alnaib, MD, from the University Hospital of North Durham in the United Kingdom, stated that at his institution use of the WHO surgical safety checklist is mandatory.

"I strongly believe that this tool has raised awareness amongst surgeons, anesthetists, and theater staff of the importance of patient safety in general, and surgical safety specifically," he told Medscape Medical News.

However, he points out that "most surgical safety–related publications are qualitative studies, and I believe that strong evidence should be drawn only from well-designed quantitative research; not necessarily trials, but from studies comparing complication rates before and after the implementation of locally adapted surgical safety checklists."

The study was not commercially funded. One authors is a member of the Advisory Board of Pulsion Medical Systems; has received reimbursement of participation fees and travel and accommodation expenses for scientific meetings and has been paid for the preparation of scientific continuing education events by Abbott, CSL Behring, Pulsion, GE Healthcare, and Merck; has been paid for the performance of scientific studies on behalf of Organon, Air Liquide, Pulsion, BMEye, and GE Healthcare; and has received funding from Pulsion, Air Liquide, BMEye, and GE Healthcare for a research project that he initiated. The other authors have disclosed no relevant financial relationships. Dr. Heidecke states that he has received payment from Johnson & Johnson and from the Aesculap-Akademie for the preparation of scientific continuing education presentations. Dr. Busemann and Dr. Alnaib have disclosed no relevant financial relationships.

Dtsch Arztebl Int. 2012;109:693-694, 695−701. Article full text, Editorial full text

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