What is the rationale for using preoperative checklists on the day of surgery?

What is pre-verification checklist?
It is a checklist that is required to be asked and assessed as part of your safe care before going for surgery.

What will I expect?
Your nurse in the Preoperative Holding or Prep area on the day of surgery will make sure that all your requirements are done before surgery. Below are some examples:

• Patient identification:
  • The nurse will ask your complete name and birthday, check your identification bracelet and compare it against your records. It is important that you accurately identify your complete name to prevent any potential errors.
• Surgical consent:
  • The nurse may witness your signature on your written surgical consent. You are encouraged to ask questions about your surgery. You need to be well informed by the surgeon. The nurse can assist you in calling your physician to answer your questions.
• History and Physical Examination:
  • Your surgeon will completely document your medical history and physical examination. Most often it is done before the day of surgery but may be done on the day of surgery too. If you had any changes in your health conditions after they had done your medical history and physical examination, you must inform your physician on the day of surgery. For example, a flu, any injury that your physician may not know, or blood transfusion.
• Surgical site signature:
  • Surgical site signature means your surgeon or designee will sign the site of your surgery to accurately identify the area of your surgery. Not everybody will have this surgical site signature. The need for surgical site signature is for patients with surgery that indicates a right or left location. For example: left leg, right arm, left eye, or right kidney.
• Blood specimen:
  • When taking blood specimen from a patient, the nurse must check the patient identification and compare it against the blood label to make sure there is a correct match.
• X-ray:
  • If you bring an x-ray film with you, the nurse will check if the label matches correctly with your identification.
• Anesthesia interview:
  • Your anesthesiologist will interview you before surgery. This is the time that you want to ask questions about your anesthesia and how your pain will be managed.
• Nurse interview:
  • The nurse will assess and ask you a lot of questions. Some of the questions may be repetitive but it is important to ask for your safe care.
• List of medications:
  • Make sure you bring your list of medications, doses and how often you take them. The medications will include both prescribed and over the counter medications, herbs and other medications like cocaine. The nurse will validate all of these medications on the day of surgery. She will either document or update what it is in your record. It is very important that we need to know all the medications that you are taking.
• Allergy:
  • You need to inform the nurse and the physician if you have taken medications that caused itchiness, redness, hives, or any discomfort after you have taken a medication.
• Devices:
  • You need to let the nurse know if you have home insulin or pain device including pacemaker and automatic internal compression device (AICD.) This is important to know so we can safely plan your care. If you have home supplies, bring extra to the hospital with you.

Reprinted with permission by the American Society of PeriAnesthesia Nurses (ASPAN).
Copyright © 2010. All rights reserved. ASPAN Patient Information. Available at: www.aspan.org.

Consider the following case: It is 07:30 on Tuesday. The operating team for OR1 has been delayed by a lengthy hand­over and planning meeting at shift change—a delay compounded by last-minute changes in the slate and an illness call from one of the nursing staff.

The scrub nurse, Mary, and the circulator, Trevor, begin the operative set-up while the anesthesia technician checks the gas machine and the volatile anesthetics, and calibrates the arterial transducer and monitor. 

At 07:40, the surgeon, Doug, and the anesthesiologist, Paul, join the nursing and technical staff and begin the surgical safety checklist briefing. 

Because Trevor is new to the surgi­cal service, team members introduce themselves. Paul describes the final slate of patients for OR1 and confirms the completion of the anesthetic equipment check and the suitability of planned monitoring. 

Doug describes the reasons for the day’s slated operations and the unique needs of the patients.

The first operation of the day is a cranial remodeling for a craniosynostosis on Jonathan, a 3-month-old infant. Trevor describes the positioning, the plan for instruments and sutures, and confirms with Doug the in-room availability of the supplies. 

Doug reviews Jonathan’s images and allergy status, pre-op blood work, and transfusion requirements with Paul. Packed RBS is confirmed to be “in the fridge,” special drugs and equipment have been made available, and preoperative antibiotics have been given.

Trevor and Paul meet Jonathan and his parents in the pre-op area—Doug has marked and initialed the surgical site in the presence of the family earlier in the morning. 

Jona­than is carried by his mother to the OR at 07:50. The team introduces themselves to Jonathan and his mother and confirms the operation and the site. Then, with his usual skill, Paul induces Jonathan without causing fear or anxiety in mother or infant. 

Trevor escorts Jonathan’s mother from the OR. The final confirmation of the patient’s identity, consent, operation, and plan is led by Doug.

In total, the pre-op briefing and the “huddle” with the patient in the room have taken only 7 minutes of the team’s time. The operation proceeds without surprises or delay, with all the equipment and sutures needed readily available.

Before the team departs the OR, while Jonathan is waking, Mary makes a suggestion for better draping and Trevor suggests a way to improve sharps handling. Both suggestions involve small changes that Doug agrees to test during the next operation.

Worldwide, approximately 11% of illness is due to surgically treatable disease,[1] resulting in the performance of an estimated 234 million surgical procedures annually.[2] 

The increased frequency of cardiovascular disease, cancer, and traumatic injuries, coupled with longer life expectancy, means significant increases in the surgical burden are likely in coming years. 

Studies in industrialized countries show that the perioperative death rate for inpatient surgery is in the order of 0.4% to 0.8% and the rate of major complications varies from 3% to 17%.[3,4] 

Of these cases, at least 50% could be prevented by minimizing the risk of surgical site infection and complications of anesthesia. Conservative estimates forecast 11 million disabling complications and 1 million deaths worldwide each year due to, or associated with, surgical illness. 
In British Columbia, surgical complications account for a significant portion of our health burden. 

During the 2007–2008 fiscal year, 119926 inpatient surgical procedures were performed. Applying the Baker and Norton findings[3] to surgical care in BC, and assuming a 7.5% adverse event rate, 8995 surgical inpatient cases with at least one adverse event would have occurred. 

Of these 8995 surgical inpatient cases with an adverse event, 3319 inpatient surgical cases (36.9%) would have had at least one preventable ad­verse event; 589 to 920 cases would have resulted in preventable deaths.
 
As each preventable adverse event results in an increased length of hospital stay—6 days on average—mitigating the preventable adverse events would result in making an additional 19 914 patient days available to address health system needs. 

Despite public outcries and efforts to avoid medical-legal culpability and meet accreditation standards, excessive rates of wound infection continue to occur in elective and clean surgeries, in part because of inconsistent timing of appropriate prophylactic antibiotics, and wrong-patient or wrong-site operations persist. 

The World Health Organization (WHO) has recognized the impact of unsafe health care practices globally and launched campaigns that challenge practitioners to implement im­provements. 

Clean Care Is Safer Care challenges practitioners to keep hand hygiene on the national and international health agenda (www.who.int/gpsc/en/); Safe Surgery Saves Lives challenges practitioners to improve surgical care around the world by ensuring adherence to proven standards, including the use of surgical safety checklists (www.who.int/patientsafety/safesurgery/en/); and Tackling Antimicrobial Resistance challenges practitioners to address the growing threat to control of infectious diseases posed by antibiotic resistance in those diseases that have long been en­demic—malaria, tuberculosis, and sexually transmitted infections, as well as seasonally occurring infections and pandemics (www.who.int/patientsafety/amr/en/). 

In formulating the Safe Surgery Saves Lives campaign, WHO iden­tified 10 objectives for safe surgery (Table). 

Each objective has been in­corporated into the surgical safety checklist to ensure correct patient, correct procedure, correct site, safe anesthesia, appropriate prophylactic antibiotic timing, and availability of fluids or blood for resuscitation.

The value of checklists
Checklists provide guidance and allow tracking of completed tasks. In the context of surgery, they aid memory and foster process standardization while providing a framework for valuation.[5] 

The use of a checklist in a team setting facilitates communication so that all team members share explicit goals.[6] Checklist use also significantly reduces the occurrence of mistakes, slips, and lapses.[7]

A checklist is typically a list of action items or criteria arranged in a systematic manner that allows the user to record or verbally confirm the presence or absence of individual conditions or items to ensure that all are considered and completed. 

Checklists differ from other cognitive aids and lie somewhere between a string-around-the-finger reminder and a protocol.[8]

The OR is a complex environment that involves consistent time-critical decision making and is thus a place susceptible to adverse events.[9] 

Human error is implicated in 70% to 80% of surgical and anesthetic incidents and accidents. Stress, fatigue, time pressures, and team dynamics affect perceptions and decision making, resulting in errors of judgment, deviations from standard procedures, and de­creas­ed proficiency.[10] 

It is accepted that during almost all procedures an unanticipated event will occur and require the surgical team to respond to a changed condition.[11] 

Although unexpected problems are typically not critical, the combination and frequency of these small incidents can affect the outcome and success of the surgery.

Improving communication
Ineffective or insufficient communication among team members contributes to error in the surgical theater.[12] This is often the result of team members’ uncommunicated perceptions of their roles, responsibilities, and motivations. 

In addition, critical information is often transferred in an ad hoc manner and typically when tension levels are high.[13]

One way to address the weaknesses of team communication is to use a checklist. By structuring team communication, a checklist assists in en­suring that all team members possess accurate and explicit information re­garding the patient and the procedural plan. 

This approach gives team members the same context for decision making and risk awareness[6] by prompting attention to critical items, and ensures that communication and discussion occurs between team members.[9,14]

Increasing efficiency
Checklists can also affect operational efficiency. Nundy and colleagues undertook an evaluation of preoperative briefings on surgical delays.[15] 

Their preoperative briefings, which each took less than 2 minutes, were designed to formulate and share the operative plan, to promote teamwork, to mitigate hazards to patients, to re­duce preventable harm, and to ensure all required equipment was available. 

Following implementation of the briefing protocol, surgeons reported that unexpected delays decreased from 38% to 7% and that communication breakdowns resulting in case start delays were also reduced. 

Briefings were shown to save time and reduce frustration while improving quality and operative efficiency.[15] They were also shown to identify problems and allow critical knowledge gaps to be addressed.[6]

Reducing complications
The use of a checklist can not only improve team communication and increase operational efficiency, it can also reduce postsurgical complication rates. 

Haynes and colleagues undertook a critical analysis of the efficacy of the WHO checklist (Figure 1) in high- and low-income health care settings, and in all adult noncardiac surgical disciplines with respect to complications and in-hospital mortality.[4] 

The study examined complication rates in 3700 patients prior to the implementation of the checklist and 3900 following implementation in several sites: Toronto, Canada; New Delhi, India; Amman, Jordan; Auckland, New Zealand; Manila, Philippines; Ifakara, Tanzania; London, England; and Seattle, USA. 

Overall complication rates dropped from 11% to 7% after the introduction of the checklist—in both high- and low-income sites—and the in-hospital rate of death dropped from 1.5% to 0.8%. Surgical site infections and mortality rates also declined significantly.[4]

Given the obvious benefits found in this and other studies, the Canadian Patient Safety Institute (CPSI) is supporting the WHO Safe Surgery Saves Lives campaign in Canada in collaboration with Accreditation Canada, the Canadian Anesthesiologists Society, the Canadian Association of Paediatric Health Centres, the Canadian Medical Association, the Canadian Nurses Association, GreenDot Global, the Nova Scotia Department of Health, the Ottawa Heart Institute, the Operating Room Nurses Association of Canada, Patients for Patient Safety Canada, the Regina Qu’Appelle Health Region, the Royal College of Physicians and Surgeons of Canada, the Society of Obstetricians and Gynecologists, Suresurgery, and the University of Calgary. 

Examples of the Safe Surgery Saves Lives checklist are available on the CPSI Safe Surgery Saves Lives web site (www.patientsafetyinstitute.ca/english/toolsresources/sssl/pages/default.aspx) along with a variety of other tools, including videos on how checklists can be used effectively in operating rooms. 

Implementation manuals and other tools have also been made available. Similar resources are available at Safesurg.org (www.safesurg.org/) and from WHO (www.who.int/patientsafety/safesurgery/en/).

The checklist in use at Vancouver Coastal Health is based on both the WHO and CPSI versions, and has been modified to meet the needs of the surgical teams involved. 

The checklist in use at BC Children’s Hospital is also based on the WHO and CPSI versions, and has been modified to account for the unique needs and risks associated with the surgery of children (Figure 2).

Conclusions
The use of a simple checklist is efficient and cost-effective. Checklists reduce frustration for members of the surgical team, reduce morbidity in health systems identical to ours, and save patients’ lives. 

Using a checklist contributes to operational efficiency, patient safety, and teamwork. In 2009, a worldwide audience watching the final episodes of ER saw this confirm­ed (see box). 

In future, you can expect your patients to ask that the checklist be used for their operations. It is your duty and responsibility to do so.

Competing interests
None declared.

References

1. Debas H, Gosselin R, McCord C, et al. Surgery. In: Jamison D, Breman J, Meas­ham A, et al. (eds). Disease control priorities in developing countries. Washington: Oxford University Press and the World Bank; 2006:1245-1260.
2. Weiser TG, Regenbogen SE, Thompson KD, et al. An estimation of the global volume of surgery: A modelling strategy based on available data. Lancet 2008;372(9633):139-144. PubMed abstract
3. Baker GR, Norton PG, Flintoft V, et al. The Canadian Adverse Events Study: The incidence of adverse events among hospital patients in Canada. CMAJ 2004;170:1678-1686. PubMed abstract
4. Haynes AB, Weiser TG, Berry WR, et al. A surgical safety checklist to reduce morbidity and mortality in a global population. N Engl J Med 2009;360:491-499. PubMed abstract
5. Scriven M. The logic and methodology of checklists. The Evaluation Centre, Western Michigan University.  www.wmich.edu/evalctr/checklists/papers/logic_methodology.htm (accessed 12 April 2010).
6. Lingard L, Regehr G, Orser B, et al. Evaluation of a preoperative checklist and team briefing among surgeons, nurses, and anesthesiologists to reduce failures in communication. Arch Surg 2008;143:12-17;discussion 8. PubMed abstract
7. Wickens C, Hollands J. Engineering psychology and human performance. 3rd ed. New Jersey: Prentice Hall; 2000.
8. Hales BM, Pronovost PJ. The checklist—a tool for error management and performance improvement. J Crit Care 2006;21:231-235. PubMed abstract
9. Leape L. Preventability of medical injury. In: Bogner M (ed). Human error in medicine. Hillside, NJ: Erlbaum; 1994. 
10. Reason J. Safety in the operating theatre—Part 2: Human error and organisational failure. Qual Saf Health Care 2005;14:56-61. PubMed abstract
11. Dankelman J, Grimbergen C. Systems approach to reduce errors in surgery. Surg Endosc 2005;19:1017-1021. PubMed abstract
12. Wiegmann DA, ElBardissi AW, Dearani JA, et al. Disruptions in surgical flow and their relationship to surgical errors: An exploratory investigation. Surgery 2007;142:658-665. PubMed abstract
13. Lingard L, Espin S, Whyte S, et al. Communication failures in the operating room: An observational classification of recurrent types and effects. Qual Saf Health Care 2004;13:330-334. PubMed abstract
14. Barker J. Error reduction through team leadership: What surgeons can learn from the airline industry. Clin Neurosurg 2007;54:195-199. PubMed abstract
15. Nundy S, Mukherjee A, Sexton JB, et al. Impact of preoperative briefings on operating room delays: A preliminary report. Arch Surg 2008;143:1068-1072. PubMed abstract

Dr Cochrane is chair of the BC Patient Safety and Quality Council. Ms Lamsdale is a human factors specialist with Vancouver Coastal Health.

D. Douglas Cochrane MD, FRCSC,, Allison M. Lamsdale, MASc,. Thank you, Dr Benton:* Rationale for using a surgical checklist in British Columbia. BCMJ, Vol. 52, No. 5, June, 2010, Page(s) - Clinical Articles.

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What is the reason for using preoperative checklists on the day of surgery?

What is the importance of preoperative assessment prior to surgery?

What is the rationale for preoperative care?