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Patient safety

Checklists found to have big impact in the OR

New research published in the New England Journal of Medicine found that when surgical teams utilized a simple checklist – as pilots do before takeoff – patient-mortality rates were cut nearly in half and complications fell by more than a third.

The study – which included 7,688 patients in eight hospitals around the world – saw death rates drop from 1.5% before the checklist was instituted to 0.8% afterward. Serious complications fell from 11% to 7%. Study sites included Seattle, London, Toronto, New Delhi, and Ifakara, Tanzania.

“We were not anticipating such a dramatic reduction,” said lead author Dr. Atul Gawande, an associate professor at the Harvard School of Public Health and staff writer for the New Yorker magazine. “We had initially planned the size of the study to pick up a 15% reduction in complications.”

The checklist comprised 19 items to be carried out throughout surgery: seven before anesthesia is administered, seven just before the first incision and the rest before the patient leaves the operating room.

The study focused on six checklist items, all involving basic safety issues, such as whether the identity of the patient, site and type of surgery were confirmed correctly, whether enough blood was readily available in case of excess bleeding and whether all the sponges used in surgery were accounted for after the procedure.

The concept of surgical checklists could have a huge impact if incorporated into all two million operations performed yearly in Canadian hospitals, experts said.

“That translates to something like 60,000 people who have operations and would be spared complications,” Dr. Bryce Taylor, chief surgeon at Toronto’s University Health Network, told the National Post newspaper. “That’s a pretty impressive number for something that doesn’t cost you anything to do.”

Toronto General, one of the network’s hospitals, was part of the eight-city study spearheaded by the World Health Organization (WHO). To inspire his doctors and nurses, Dr. Taylor at one point had a senior Air Canada training pilot speak to them about the concept.

Experts said that the idea – which they called inexpensive and relatively simple – be implemented by all Canadian hospitals as soon as possible.

Patient safety has become an increasingly pressing issue in the wake of research that highlighted the problem of medical error, or “adverse events,” as they are called in the system. A 2004 study estimated that 9,000 to 23,000 people die in Canadian hospitals annually because of preventable adverse events, out of 2.5 million yearly admissions.

Of those errors, the largest number occur during or after surgery, said Dr. Ross Baker, a University of Toronto health policy professor who co-authored the 2004 study.

“It is one of the areas where we have tremendous skills and resources,” Dr. Baker said. “And then we go in and somebody forgets to do something they should do as a matter of course, and the outcome is an infection or complication of some sort.”