t h e s u r g e o n 8 ( 2 0 1 0 ) 1 – 4

avai lable at www.sciencedirect .com

The Surgeon, Journal of the Royal Collegesof Surgeons of Edinburgh and Ireland

www.thesurgeon.net

Editorial

The surgical safety checklist effects are sustained, and teamculture is strengthened

The surgical safety checklist has prompted much discussion

around the world, and has to some extent challenged tradi-

tional surgical practice. The fundamental premise that a true

team approach is safer and more efficient than the traditional

pyramidal hierarchy in the operating room has offended

some, and has been unconvincing to others; there has been

the contention that the data supporting the use of the

checklist1 have been the product of ‘‘soft science’’. A number

of questions have been repeatedly posed by those who have

had either doubts, or problems in implementing this new

change of practice (or standard operating procedure):

1. How should the checklist be introduced to an operating

facility?

2. How could a surgeon work this into his/her tight schedule?

3. How do you avoid ‘‘refractoriness’’ or ‘‘checklist fatigue’’?

4. Should we have more than one checklist in our operating

room?

5. Is a mandated checklist the best way to introduce this to

a hospital or larger jurisdiction such as an American state,

a Canadian province or a whole country?

6. Do we need further evidence that the checklist demon-

strates improved outcomes in our setting before adopting,

and which of the 17–20 items are the most important in

reducing complications?

7. Is the conduct and acceptance of the checklist sustainable

over time, or will its meaning and compliance deteriorate?

8. Does this addition have an effect on staff satisfaction?

As representatives of one of the eight participating sites in

the World Health Organization study, we feel we are in

a position to give opinions on these questions, having had one

and a half years of experience instituting the surgical safety

checklist across a three-hospital academic organization

which performs almost 25,000 operations per year.

It should be emphasized that the concept of checklists is

not novel – in addition to the often cited airline analogy,

nurses in fact have been using checklists for decades in

ensuring proper identification of patients, preoperative prep-

aration and the like. The well-described central line infection

rate improvements after institution of a simple insertion

checklist were well documented in 2006.2,3

Despite the published data reporting a reduction in

complications when a surgical safety checklist was used,1

independent practitioners have been sometimes reticent to

adopt this tool, perhaps as that adoption may imply that their

previous practice was imperfect. On the other hand, we

concede that the interpretation of the data must be

approached carefully; any extrapolation of a 0.7% reduction in

mortality and a 4% reduction in the frequency of complications

to the 234 million operations carried out annually around the

world is risky – after all, one would be assigning conclusions to

a data set 30,000 times greater than the study of a heteroge-

neous group of 8000 patients! However, we are comfortable in

concluding that in the high-income cohort (Seattle USA, Tor-

onto Canada, London England and Auckland New Zealand),

complication rates were reduced when a surgical checklist was

used. And we believe these results are generalizable.

We would postulate that there are many reasons why our

initial experience with the checklist has been a positive one.

First, one major assumption was that many errors of omission

or commission result from communication failures,4 and so the

idea of team members communicating more efficiently and

respectfully seemed only rational. Second, this process that was

not top–down driven, and had wide buy-in from individuals in

many healthcare professions. For example, in our hospital, we

had the advantage of having a group of nurses and surgeons

who had previously been experimenting with this concept,4 and

whose enthusiasm was well known to other colleagues in the

operating room. These thought leaders were convinced that the

atmosphere or culture in their particular OR’s had improved,

and consequently they were able to engage and inspire others.

We referred to these non-leader/enthusiasts as our ‘‘cham-

pions’’. Third, we constructed our own surgical safety checklist,

with modifications of the WHO template appropriate to our case

mix and practice. Fourth, many hours were spent coaching,

reminding and supporting the various operating room teams

during the checklist introduction. It is important to note that

this encouragement was not punitive, but rather a collaborative

approach to working together on a project. Equally important

was the fact that one of us visited every operating room every

day for about one month until it was felt that the process was

becoming more automatic. Fifth, from the start, compliance was

registered on ORSOS, our electronic operating system, so that

t h e s u r g e o n 8 ( 2 0 1 0 ) 1 – 42

we had real-time compliance rates and operating rooms or

teams that needed specific reminders were flagged. Sixth, it was

impressed on all team members that they had a responsibility and

accountability to be a member of the team, and were expected to

participate; each had to actively confirm certain aspects of the

list, thus declaring that responsibility. These moves were

designed to create true teams in which, in business terms, the

hierarchal ‘‘pyramid was flattened’’. Additional points con-

cerning the implementation in our operating rooms can be

found on the Canadian Patient Safety Institute Web site.5

It’s clear that for surgeons in particular to participate in all

aspects of the checklist, a change in time management must

be considered. The surgeon who previously arrived for a 0800

case after the patient was anesthetized, now sees the patient

in the preoperative area for greeting and incision marking,

returns for the checklist briefing just before 0800, and then

returns again perhaps 30–45 min later for the incision, if

a complex case is preceded by extensive anesthetic prepara-

tion such as arterial line, CVP line and epidural insertion. (In

some hospitals of course, these maneuvers may be achieved

outside the operating room). This kind of process requires

preparation on the part of the surgeon who may fill these time

periods with a variety of useful activities.

As with any checklist, the team must guard against what

we call ‘‘tick and flick’’, a routine by which the various

elements of the list are acknowledged, but not really consid-

ered carefully. We liken this to surgical rounds in the morning

– some make very cursory rounds not really probing the

patient’s problem carefully, and others truly ‘‘troubleshoot’’

on every patient. In both instances of the rounds and the

checklist, the fastidious surgical mind is well trained to avoid

the trap of inattention to detail.

We have frequently been asked whether the same check-

list should be used for heart transplants and cataract proce-

dures under local anesthetic. Although at our institution we

have used the same checklist for both, this question under-

scores one important point; it’s not so much the exact

composition of the document that’s critical, as the communi-

cation and conversation that takes place among the team

members to create a healthier culture. Since every hospital is

encouraged to ‘‘make it their own’’, it might be quite reason-

able to have two different checklists (with common elements)

that could be employed in different situations.

In publicly run hospitals, it was inevitable that various

jurisdictions would see it as their mission to mandate

a simple improvement strategy like a surgical checklist.

While the endpoint may be clear, sustainability of such

a process is more reliable if healthcare providers embrace it

because they believe in it, rather than because they are told to

do it, especially if those healthcare providers are indepen-

dent surgeons or anesthesiologists. The use of checklists may

in future be mandated, either by a specific hospital or by the

adoption of the checklist as an accreditation standard. We

believe the major drivers for a change of practice will be

patient expectations supported by a body of confirmatory

scientific evidence. Currently several jurisdictions have plans

to mandate the introduction of checklists as an expansion of

the traditional ‘‘timeout’’ procedure; the state of Washington

in the United States,6 the province of Ontario in Canada,7 the

National Health System in Great Britain,8 and the Ministry of

Health in Jordan9 now have or will have in the very near

future, obligatory reporting of checklist introduction. Perhaps

the intransigent surgeon or anesthetist who is reluctant to

adopt this tool will be convinced only when the lawyers

begin asking during discovery of a legal action for an unex-

pected complication ‘‘was the checklist used in this

operation?’’.

Much talk has circled around the continuous follow-up of

postoperative patients for all outcomes, especially surgical

complications, as was done in the WHO study. Some clini-

cians have suggested that they need more evidence in their

setting before they would enthusiastically adopt the checklist.

It should be noted that the cost for collecting data on the

approximately 1000 cases that our hospital contributed to the

study, was approximately $60,000 CDN. The cost of following

all patients in a similar way would be prohibitive. Most centres

have chosen therefore to try to control the process indicators

that are known to cause complications, especially if that

control is inexpensive. Take, for example, the issue of surgical

site infection (SSI). Fastidious wound surveillance requires

multiple visits by a nurse, a wound culture and data collec-

tion. Rather than objectively following every patient post-

operatively for the development of infection, it might be more

cost-effective to attempt to control the known potential

process indicators, specifically clipping not shaving, appro-

priate administration of the correct antibiotics, and mainte-

nance of both normothermia and normoglycemia.10 We trust

that if an operation is performed with acceptable aseptic and

atraumatic technique and those four factors are embraced,

the incidence of SSI will be minimized. One might regard the

conduct of the surgical safety checklist in the same way. For

those who wish to ‘‘tighten the checklist’’ to a smaller number

of elements, we would respond as follows: (a) every hospital

can decide how to approach the issue, (b) it’s all about the

conversation anyway, and (c) even the longer checklist takes

only about 2 min to perform.

The statement that the positive outcomes seen with the use

of the checklist may be due to the Hawthorne effect seems an

obvious one.11 This perioperative tool is designed to cover

details and avoid errors of omission and commission; if we are

being watched, attention to those details will naturally be

meticulous. A mechanism to further evaluate the potential

existence of the Hawthorne effect would be to rigorously assess

and report compliance. However, after months or years, if

positive results were due to the Hawthorne effect, we would

expect a decay in positive results unless a change in culture has

taken place wherein the new tool becomes as much part of the

operation as a knife cutting skin. We have some confirmatory

data that such a culture change can and does occur. We

examined this issue through a questionnaire administered to

operating room personnel 18 months after introduction of the

checklist. Surgeons, anesthetists and nurses were asked their

opinions on the effect of the checklist on surgical practice, and

answers were recorded on a ten-point Likert scale. Figs. 1 and 2

demonstrate that surgeons, anesthesiologists and nurses

agreed for the most part that the checklist was convenient and

took little time, that if they themselves were to have an oper-

ation, they would prefer that the checklist be used, and that

improvements in team culture had occurred. Not surprisingly,

however, nurses were more emphatic about the

t h e s u r g e o n 8 ( 2 0 1 0 ) 1 – 4 3

improvements, as presumably they had clearly been disen-

franchised previously, many feeling as though they had been

reduced to running errands at the whim of the surgeon or

anesthesiologist. they were now full team members.

q1

• Do you think the use of the checklist has improved patient safety at UHN?

0

1

2

3

4

5

6

7

8

9

10

nurse

anesth

surgeon

nurse

anesth

surgeon

Not at all

To some

degree

Yes!

nsns

q3

• How much time does the checklist take?

0

1

2

3

4

5

6

7

8

9

10

minutes

nsns

•

**

q5

• Are you comfortable in reminding other members of the team to carry out the checklist?

0

1

2

3

4

5

6

7

8

9

10

nurses

anesth

surgeon

nurses

anesth

surgeon

Very

uncomfortable

Somewhat

uncomfortable

Very

comfortable nsns

q7

• Some have said that the checklist has helped in creating a better sense of “team”in the OR setting…do you agree?

0

1

2

3

4

5

6

7

8

9

10

disagree

Agree

somewhat

Agree!

** p<0.008p<0.008

**

•

Fig. 1 – Responses by nurses, anesthesiologists and surgeons

Another yardstick of acceptance is the employee satisfac-

tion measurement or employee opinion survey (EOS).12 These

metrics are formally and objectively obtained every three

years in our environment, and the difference in results

nurse

anesth

surgeon

nurse

anesth

surgeon

q2

• Do you find the conduct of the checklist inconvenient?

0

1

2

3

4

5

6

7

8

9

10

Not at all

To some

degree

Yes!

nsns

q4

If you were to undergo surgery, would you want the checklist to be used?

0

1

2

3

4

5

6

7

8

9

10

Don’t

care

Moderately

positive

Yes!**

p<0.0001p<0.0001

nurses

anesth

surgeon

nurses

anesth

surgeon

q6

• When you remind other members of the team to carry out the checklist, do you get pushback?

0

1

2

3

4

5

6

7

8

9

10

never

sometimes

always

**

** p<0.001p<0.001

q8

Do you think that use of the checklist generally has improvedcommunicationamong members of the OR team?

0

1

2

3

4

5

6

7

8

9

10

Not at all

somewhat

Yes!

** P<0.002P<0.002

**

to a questionnaire 18 months after checklist introduction.

Fig. 2 – Results of ORGANIZATIONAL COMMITMENT element

of the employee opinion survey, TGH OR’s, 2006 & 2009.

Fig. 3 – Results of 6 major elements of EOS, TGH OR’s, 2006

& 2009.

t h e s u r g e o n 8 ( 2 0 1 0 ) 1 – 44

between 2006 and 2009 is significant (Fig. 3). The major factors

in this three-year period that might explain such a striking

improvement were the execution of the so-called ‘‘OR

Transformation Project’’ and the introduction of the surgical

safety checklist. The OR Transformation Project included

attention to a number of perioperative efficiency improve-

ments, and the articulation of a ‘‘team charter’’, a perioper-

ative code of conduct that was prepared by a large number of

representatives from nursing, surgery and anaesthesia. The

most evident daily intervention, however, was the introduc-

tion of the surgical checklist, and members of especially the

nursing staff in particular felt that the consequent team

building and enhanced culture were palpable, as seen in

results of the checklist questionnaire.

In summary, the success of any new change of practice

depends on a number of factors. The ideal setting for change

involves clear recognition of a problem, a desire to correct that

problem, an intervention to mitigate the problem, evidence

that the intervention is effective, inexpensive, doable, and not

disruptive. Keys to successful change are guidance by

passionate leadership and execution by committed staff. The

surgical safety checklist has demonstrated all these charac-

teristics, and it is our opinion that it has been effective in

promoting a team approach in our operating rooms. If teams

persist in its implementation, a more effective and positive

workplace and development of a strong team culture will be

the results; patients will be the real beneficiaries.

r e f e r e n c e s

1. Haynes AB, Weiser TG, Berry WR, Lipsitz SR, Breizat AS,Dellinger EP, et al. for the Safe Surgery Saves Lives StudyGroup. A surgical safety checklist to reduce morbidity andmortality in a global population. N Engl J Med January 29, 2009;360(5):491–9.

2. Berenholtz SM, Pronovost PJ, Lipsett PA, Hobson D, Earsing,Farley JE, et al. Eliminating catheter-related bloodstreaminfections in the intensive care unit. Crit Care Med 2004;32(10):2014–20.

3. Pronovost P, Needham D, Berenholtz S, Sinopoli D, Chu H,Cosgrove S, et al. An intervention to decrease catheter-relatedbloodstream Nurses, and Anesthesiologists to ReduceFailures in Communication. infections in the ICU. N Engl J MedDecember 28, 2006;355(26):2725–32.

4. Lingard L, Regehr G, Orser B, Reznick R, Baker GR, Doran D,et al. Evaluation of a preoperative checklist and team briefingamong surgeons, nurses, and anesthesiologists to reducefailures in communication. Arch Surg 2008;143(1):12–7.

5. http://www.patientsafetyinstitute.ca/English/toolsResources/sssl/Pages/SurgicalSafetyChecklist.aspx.

6. http://www.scoap.org/checklist/.7. http://www.health.gov.on.ca/en/news/release/2009/oct/

patientsafety_1year_nr_20090922%20_2_.pdf.8. National Patient Safety Agency. National reporting and learning

system. Putting patient safety first, www.npsa.nhs.uk/nrls/; 2008.9. Breizat AH. Personal communication.

10. Andrea Kurz, Sessler Daniel I, Rainer Lenhardt for The Studyof Wound Infection and, for Temperature Group.Perioperative normothermia to reduce the incidence ofsurgical-wound infection and shorten hospitalization. N Engl JMed May 19, 1996;334(19):1209–16.

11. Vijayasekar C, Steele RJC. The World Health Organization’ssurgical safety checklist. The Surgeon October 2009;1:260–2.

12. NRC þ Picker Canada Employee Opinion Survey of UniversityHealth Network 2006 and 2009.

Bryce Taylor*, Anne Slater, Richard Reznick

University Health Network, R. Fraser Elliott Building 1-408, 219

Gerrard St. West, Toronto, Ontario, Canada M5G 2C4

University of Toronto, Surgery, R. Fraser Elliott Building 1-408, 219

Gerrard St. West, Toronto, Ontario, Canada M5G 2C4

*Corresponding author. Tel.: +1 416 340 3558; fax: +1 416 340

3185.

15 November 2009

1479-666X/$ – see front matter

ª 2009 Royal College of Surgeons of Edinburgh (Scottish

charity number SC005317) and Royal College of Surgeons in

Ireland. Published by Elsevier Ltd. All rights reserved.

doi:10.1016/j.surge.2009.11.012