Yes, We Need a Checklist

On my desk sits a checklist of things I need to do this week (writing this column among them). It's nothing fancy—just a handwritten outline that I tweak as the days progress. Some items are more urgent than others; while I try to get to everything, at least a couple of tasks inevitably get bumped to the following week.

The thing is, if I'm too busy to complete every project or I just plain forget something, the consequences usually aren't terribly dire—I just work a little harder the next day or the next week. At least some of the time, I'm lucky enough to have that option in my profession. But what if a surgical team skips an item on its checklist before, during, or after an operation? Sometimes, the patient never knows the difference. Other times, the patient definitely knows the difference. And still other times, the patient dies.

A study published last week in The New England Journal of Medicine found that implementing a 19-item surgical safety checklist based on World Health Organization guidelines lowered deaths rates by nearly half and reduced inpatient complications from 11% to 7%. "Applied on a global basis, this checklist program has the potential to prevent large numbers of deaths and disabling complications," the authors wrote in the study, which involved more than 7,600 patients in eight hospitals in eight different countries over the course of one year.

I really don't need a study to tell me that a surgical checklist can help keep patients safer. I suspect most of you don't, either. Oh sure, I suppose it's nice to have concrete data to support certain suppositions, and I appreciate the efforts of the researchers. But come on. The checklist includes everything from confirming patient identity and allergies to introducing team members during timeout to postoperative instrument and sponge counts. Uh, yes—surgical teams should do those things.

What I would like a study to tell me is why such lists aren't already standard procedure everywhere. Yes, traditional surgical timeouts include many things on the WHO checklist. But addressing "most" of the list isn't good enough—all it takes is one missed item to endanger a patient unnecessarily. And I realize that ingrained cultural or operational issues in many organizations can complicate the implementation of seemingly simple procedural changes in ways I can't fully understand unless I'm a surgical clinician, which I'm not.

But is the fact that changing processes or individual behavior can be difficult any kind of excuse? "Implementation proved neither costly nor lengthy. All sites were able to introduce the checklist over a period of one week to one month," the study's authors wrote. "Only two of the safety measures in the checklist entail the commitment of significant resources: use of pulse oximetry and use of prophylactic antibiotics. Both were available at all the sites, including the low-income sites, before the intervention, although their use was inconsistent."

There you go. It doesn't cost a lot of money, it doesn't take a lot of time. Momentum has been building to make surgical checklists a higher priority; in his address at the Institute for Healthcare Improvement's National Forum in December, President and CEO Donald Berwick, MD, said the IHI is asking each hospital in the 5 Million Lives Campaign to adopt the WHO checklist in at least one operating room. And in this case, I don't believe that many providers would dispute the potential benefits of following such a list. It's the speed of change that remains to be seen.