Surgical safety checklist saves lives?

The WHO Safe Surgery Saves Lives Study Group hasrecently published a study of surgical outcomesbefore and after implementation of a surgical safetychecklist in the New England Journal of Medicine.1

After implementation, deaths were reduced by 47%and in-hospital complications by 36%. The observedimprovement was seen across eight different studyhospitals based in high, middle and low income coun-tries. As suggested by the authors, whereas the exactmechanism for the observed improvements in out-comes is unclear, it is almost certainly multifactorial.

On the basis of these startling results, the NationalPatient Safety Agency in the United Kingdom hasissued an alert mandating that an adapted version ofthe checklist should be completed for every patientundergoing a surgical procedure in England andWales, with full implementation by February 2010.2 Thegoals are quite clear – to improve anaesthetic safetypractices, to ensure correct site surgery, to avoid sur-gical site infections and to improve communicationwithin the team. Although the checklist looks simple,logical and impressive, the sceptics are quietly watch-ing its development.

Some surgeons or surgical units that do not imple-ment such a checklist would show people a cleanbalance sheet with no mishaps in their own results toprove that there is no need of such a checklist. Somewould suggest that their current practice of ‘time-out’or ‘briefing’ would be more than adequate in prevent-ing surgical incidents. Worse still, some may simplyregard the adoption of such a checklist as an admis-sion that their practices are unsafe. Perhaps, byadopting a checklist, as is done in aviation and otherindustries, some would feel a drop in the professionalpride of their work in hospitals.

Whether surgeons around the globe would embracethis new wave of surgical safety checklists with openarms remains to be seen. Some surgical units woulduse the top-down approach and some would usethe bottom-up approach. It does not really matter thatmuch. The devil is there in the implementation. Forexample, mechanical compliance with a simple tick-box exercise would not bring about any significantchanges. Underneath that single sheet of paper is theneed to change our surgical culture – surgeons areexpected to be safer than just safe. If we surgeonsbecome patients ourselves, wouldn’t it be nice to knoweveryone in the operating theatre (OT) – anaesthetists,surgeons and nurses – are spending a few minutes(while you have been put to sleep with a tube in yourthroat!) ensuring that all OT team players know thesurgical plan and have the correct instruments handy?

Paul B.S. LaiDepartment of Surgery, Prince of Wales Hospital,

The Chinese University of Hong Kong, Hong KongSAR

References

1. Haynes AB, Weiser TG, Berry WR, Lipsitz SR, Breizat AH,Dellinger EP et al. A surgical safety checklist to reduce mor-bidity and mortality in a global population. N Engl J Med2009; 360: 491–99.

2. National Patient Safety Agency. Patient Safety Alert. WHOSurgical Safety Checklist. 2009. [Cited 19 Mar 2009.]Available from URL: http://www.npsa.nhs.uk/nrls/alerts-and-directives/alerts/safer-surgery-alert/

Surgical Practicedoi:10.1111/j.1744-1633.2009.00443.x Editorial

Surgical Practice (2009) 13, 31 © 2009 The AuthorJournal compilation © 2009 College of Surgeons of Hong Kong