It is estimated that many of the complications that occur within the hospital setting are associated with surgical procedures. While some complications, such as sepsis and bleeding, are affected by the underlying pathophysiological process, others result from adverse perioperative events or unintended harm to the patient. Therefore, implementation of preventive measures and early identification of perioperative adverse events is essential to minimizing patient injuries.

Communication failure, particularly among different disciplines, occurs frequently in operating rooms and affects many intraoperative interactions. Accordingly, interventions aimed at improving communication can prevent avoidable surgical complications. A core strategy to improve patient safety is to foster effective interdisciplinary communication. Preprocedure checklists are effective tools to improve such communication and can significantly and effectively reduce the risk of complications.1,2

OVERVIEW

The use of procedural and surgical safety checklists has become standard practice at most institutions. Many organizations and regulatory bodies have produced checklists. One example is the Joint Commission’s checklist, called “Universal Protocol for Preventing Wrong Site, Wrong Procedure, and Wrong Person Surgery.”

Safety checklists have a long history of use in medical and other high-stakes industries, such as aviation (Figure 1). In the field of medicine, safety checklists have been shown to be valuable in both routine and emergency situations across numerous health care settings (Figure 2). The checklists are modified to suit local and regional requirements, to conform to various practice settings, and to account for differences in local cultures.

Figure 1.:

Conducting a preflight aviation checklist. Safety checklists are routinely used in aviation and other high-stakes industries.

Figure 2.:

Checklist in an ambulance. Safety checklists are used in a variety of settings, including emergency patient transport.

Checklists are more effective when they are introduced with a thoughtful implementation plan. Checklists are less effective when they are simply printed and placed in an operating room. The organization must have a safety culture that embraces checklists. Training is also necessary.3 The increasing number of procedures performed outside the operating room, with or without the involvement of anesthesia personnel, demands a fundamental understanding of procedural and surgical safety checklists.

This article and the associated video present an approach to using a safety checklist in perioperative settings.

PROCESS OF CARE

Procedural and surgical safety checklists include key elements that are addressed to reduce risks and potential complications. In addition to the perioperative area, safety checklists are also valuable when caring for patients in other settings, such as the intensive care unit and the emergency department, and when performing gastrointestinal endoscopy, diagnostic and interventional radiologic procedures, interventional pain procedures, and cardiac catheterization. Procedural “time out” checklists involve members of a multidisciplinary team, all of whom participate, communicate, and temporarily cease any distracting duties.

COMMUNICATION, TEAMWORK, AND CREW RESOURCE MANAGEMENT

Procedural and surgical safety checklists encourage communication, teamwork, and crew resource management. “Crew resource management” is a term that gained popularity from its use in aviation and has become fundamental to patient safety. In the medical environment, “crew resource management” refers to the use of available staff and supplies to deliver the best possible care, reduce human error, and respond efficiently and appropriately to emergencies or unforeseen problems. Key aspects relevant to crew resource management include communication, situational awareness, assertiveness, and leadership, all in the context of a flattened hierarchy.

Safety checklists encourage communication of essential information at key moments in care, such as verification that the patient, procedure, and site are correct before the procedure is initiated. Optimizing the use of checklists requires effective patterns of communication, such as closed-loop communication. In closed-loop communication, one team member—the sender—verbalizes information (Figure 3). Another team member repeats the information and thereby becomes the sender of feedback, to indicate that the original message has been acknowledged, understood, and, if appropriate, acted on.

Figure 3.:

Closed-loop communication. In closed-loop communication, one team member—the sender—verbalizes information. Another team member—the receiver—repeats the information to indicate that the message has been acknowledged.

The format of safety checklists can vary between styles such as “read and do,” in which the checklist items are read and actions are completed, and “do and confirm,” in which key steps have been completed, and a checklist is used to confirm that nothing was missed.

Safety checklists can include prompts for all team members to introduce themselves by name and role. These lists can also be used to encourage all team members to voice observations and concerns and ask questions regarding anticipated events. This approach promotes inclusive leadership, which can enhance behaviors that promote patient safety.

CHECKLIST USE IN A PERIOPERATIVE SETTING

Important safety steps should not be omitted from the checklist, which should be modified in keeping with local requirements and the nature of the procedure to be performed. Haphazard use of the checklist, such as failing to complete all the items on the checklist or reviewing the list without the presence of all relevant staff members, can compromise the efficacy of the team.

Although the preoperative phase of care is not a direct target of surgical safety checklists, successful implementation of the items on the list depends on careful identification of the patient and confirmation of the procedure, and surgical site before the patient enters the operating room. Before the patient enters the operating room, it is important to confirm the identity of the patient with at least 2 identifiers, such as the patient’s name, date of birth, and medical record number, and to make sure that this information matches the information in the medical record and on the patient’s identification bracelet. It is also important to confirm that the procedure and the site of the procedure are consistent with the patient’s records.

Whenever possible, involve the patient in the checklist process to confirm that the information you have is correct (Figure 4). Make sure that information about the patient’s history, physical examination, medications, and allergies, as well as relevant laboratory results, is up to date and available. Verify that all items that may be required during the procedure are present. These items may include medical devices, implants, blood products, and other items that are specific to the procedure.

Figure 4.:

Conducting a safety checklist. Whenever possible, involve the patient in the checklist process to confirm that the available information is correct.

The surgeon should review the procedure with the patient and address any questions or concerns. The surgeon then completes the preoperative record and initials the site of the surgery with a presurgical skin marker. Another provider repeats the verification process, confirming the patient’s identity as well as the type and site of the procedure. The provider should also discuss other perioperative considerations, including the patient’s medical history, allergies, and fasting status.

Once the patient is transferred to the operating room and before induction of anesthesia, a designated member of the team should go through a checklist, with all team members present. It is important to confirm that a safety belt has been applied. All team members should introduce themselves by name and role, and the patient’s identity and consent to undergo the procedure, as well as the nature and the site of the procedure should be reconfirmed.

The team should discuss the critical steps and the duration of the procedure. Verify that the procedure site is marked on the patient with the surgeon’s initials. Make sure that all medications are labeled and confirm that the pulse oximeter has been placed on the patient and that it is functioning. Also, discuss the possible need for antibiotic prophylaxis as well as other procedure-specific items such as the availability of essential imaging equipment. Prompt all team members to voice any concerns related to the patient or the procedure. After the surgical area has been prepped and draped but before a surgical incision is made, verify that the surgeon’s initials are visible on the intended surgical site.

After completion of the procedure and before the patient is removed from the operating room, conduct the final intraoperative step of the safety checklist, which includes stating the name of the procedure and performing the instrument count. Read aloud the patient’s name on any specimen-container labels. Also, confirm that all equipment has been appropriately stored or removed and is in working order. Review any concerns regarding the patient’s postoperative recovery and provide the staff with the opportunity to make any final comments.

CHECKLIST IMPLEMENTATION

Successful implementation of safety checklists relies on the participation of all members of a multidisciplinary team. Checklists that are poorly designed and implemented, or viewed as perfunctory, are less likely to improve outcomes.

Factors that can facilitate checklist implementation include:

Conducting a needs assessment Reviewing clinical evidence, guidelines, and local regulations Obtaining multidisciplinary participation and leadership support Customizing the checklist Establishing implementation champions who dedicate themselves to supporting the process Developing training programs and other activities that will ensure sustained use and periodic refinement of the checklist SUMMARY

Procedural and surgical safety checklists include evidence-based care processes that are intended to enhance behaviors that support patient safety and promote adherence to time-sensitive clinical care. Checklists can increase detection of potential safety hazards and decrease the risk of complications. Importantly, procedural and surgical safety checklists should be integrated into quality-improvement efforts and organizational culture with local customization for successful implementation.4

With careful development and thoughtful implementation, procedural and surgical safety checklists can be viewed as part of a continuum of improvements toward a culture of safety and high-quality care.

DISCLOSURES

Name: Mauricio Gonzalez, MD.

Contribution: This author helped with the conceptualization, writing, and reviewing of the video.

Name: Karolina Brook, MD.

Contribution: This author helped with the conceptualization, writing, and reviewing of the video.

Name: Alexander Arriaga, MD, MPH, ScD.

Contribution: This author helped with the reviewing of the video.

Name: Rebecca Hayes, DNP, MHA.

Contribution: This author helped with the reviewing of the video.

Name: Ala Nozari, MD, PhD.

Contribution: This author helped with the conceptualization, writing, and filming of the video.

Name: Rafael Ortega, MD.

Contribution: This author helped with the conceptualization, writing, filming, and editing of the video.

This manuscript was handled by: Richard C. Prielipp, MD.