Implementing checklists may require a culture change in operating room

October 1, 2010

After my colleagues and I implemented a highly successful obstetric safety program at Yale New Haven Hospital to reduce adverse outcomes, we naively thought we could easily duplicate our safety efforts in the operating room for gynecologic surgeries by implementing a checklist such as one we had read about in an article published in the New England Journal of Medicine.

The WHO checklist Haynes and his colleagues used required oral confirmation by surgical teams of basic practices designed to ensure safe anesthesia and surgery. It was administered at 3 critical junctures: 6 items before induction of anesthesia (sign in), 7 before incision (time out), and 5 before the patient left the OR (sign out). Items included identifying drug allergies and confirming that antibiotic prophylaxis was given, that the pulse oximeter was functioning, that the surgical site was correct, that expected blood loss was estimated and prepared for, and that sponge and instrument counts were completed. Each pause point allowed for discussion of special conditions and requirements engendered by that particular case.

The researchers collected pre- and postintervention data on surgical processes and outcomes from nearly 8,000 patients undergoing noncardiac surgery. They reported a drop in perioperative death rates that could be attributable to the checklist from 1.5% to 0.8% (P=.003) and of inpatient complications from 11.0% to 7.0% (P<.001). Rates of infection fell almost 55%, and unanticipated returns to the OR fell by 25%.

Frustrated, I sought the wisdom of a key champion of the WHO study, Atul Gawande, MD, MPH, and read his book, The Checklist Manifesto.3 The book was an eye opener. Gawande points out that checklists have not only transformed the airline industry but are an indispensable tool in many areas of human endeavor requiring diverse expertise, high technology, and great complexity. For example, he notes that checklists and team meetings to discuss unexpected problems are absolutely crucial to modern skyscraper construction. He contends that construction checklists and group meetings "supply a set of checks to ensure the stupid but critical stuff is not overlooked, and . . . to ensure people talk and coordinate and accept responsibility while nonetheless being left the power to manage the nuances and unpredictabilities. . . . " As a consequence, the annual avoidable building failure rate in this country is only 0.00002%.

Gawande says that even low-tech businesses that are far more art than science, such as cutting-edge restaurants and rock concerts, use checklists leavened with frequent time outs for preemptive modifications. Yet, despite the fact that 1 million people die of preventable surgical complications each year, checklists have not permeated our national OR culture. Gawande emphasizes that checklists are needed to overcome not only our inherent fallibility but also our very nature. He argues: "We are built for novelty and excitement, not for careful attention to detail."