Do medical checklists improve patient safety or not?
Probably the best known medical checklist is the WHO Surgical Safety Checklist, which was developed by WHO’s Safe Surgery Saves Lives program led by Atul Gawande, MD. Dr Gawande is Professor in the Department of Health Policy and Management at the Harvard School of Public Health, is a surgeon at Brigham and Women’s Hospital Professor of Surgery at Harvard Medical School, and is the author of “The Checklist Manifesto”.
However, recent research on surgical safety checklists published in JAMA Surgery by Matthias Bock, MD and his colleagues in Italy found only some benefits in the use of surgical safety checklists (SSCs). They write:
The data cannot prove causality owing to the study design [emphasis added]. The implementation of SSCs was associated with a 27% reduction of the adjusted risk for all-cause death within 90 days but not within 30 days. The adjusted length of stay was reduced after implementation of SSCs.
So, are Dr. Bock and his colleagues right that there may only be marginal benefit to SSCs?
In a commentary on Dr. Bock’s research, William Berry, MD, MPH, Alex Haynes, MD, MPH; Janaka Lagoo, MD wrote that study design may indeed have impacted results:
First, whether SSC performance underwent direct observation during implementation and wether that observation compared with reported performance are unclear. Checklist performance appears to be measured primarily by checking whether a form was completed. Significant discordance between paper checklist completion and actual completion has been described. Second, 80% completion was considered the threshold for complete implementation in this study, whereas recent literature supports that full rather than partial checklist completion provides an opportunity for significant improvement of the effect of the SSC on the quality of patient care and surgical safety. With more effective implementation and full use SSC use in every case, the improvement in outcomes seen could have been even [more]. If the SSC is not used, it cannot help.
In short, the full benefits of using checklists will only be realized if they are effectively implemented, Berry et al write:
Although some investigators question the actual impact of checklists, despite proliferation of evidence regarding improved patient outcomes and quality of care across countries, these arguments fail to acknowledge fully the difficulty of effectively implementing SSC’s in a complex health system. A focus on the systems of care and promotion of a culture of safety at the institutional level is necessary to optimize checklist implementation and realize its full potential. Effective implementation is critical to meaningful use of SSC’s, which can lead to maximally improved outcomes.
How can safety checklists be implemented more effectively?How can safety checklists be implemented more effectively? #ptsafety Click To Tweet
KershawHealth, a 120-bed hospital in a town of about 7,000 in north central South Carolina, recommends 6 must do’s to successfully implementing surgical safety checklists:
- Survey all staff about what hindered checklist use.
- Identify a physician champion to get surgeons on board.
- Do monthly assessments to track how often the checklist process was skipped.
- Use peer pressure because “no one wants to be seen as the outlier”.
- Allow staff to continually update and tweak the checklist.
- Prominently post reminders in the OR about timeouts and debriefs.
As an organization that has helped enable the development of The PCA Safety Checklist (Dr. Gawande was part of the expert panel involved in its creation) and two recommendations on blood clots, we would like to know what you think of safety checklists?Do surgical #safety #checklists improve health outcomes? #ptsafety Click To Tweet