Standardize Your Surgical Safety Checklist

Confirm the right steps have been taken for every patient, every time.

The best way to mitigate risk is to catch it before it happens. 

That’s the whole idea behind standardizing a surgical checklist — providing constant confirmation to safely ensure the patient’s care.

Checklist fundamentals

Consistent preoperative routines eliminate variations in practice that lead to preventable errors. Here are the basic ways in which surgical teams can deliver elements of safe surgery, courtesy of Robert Taylor, RN, BS, clinical director, total joint coordinator and infection preventionist at Constitution Surgery Center East in Waterford, Conn.:

• Confirm the patient’s identity, first and foremost. This is quintessential, according to Mr. Taylor. “I tell patients this is our practice and we’re not asking these questions because we forgot or because we don’t know,” he says. “We do this because we check and we recheck and we ask these questions repeatedly as part of our practice to ensure your safety.”
• Review the patient’s allergies and medications. “It’s a time-consuming process,” says Mr. Taylor. “If somebody tells me they have an allergy to a common medication, and it gets missed and the doctor orders a that drug, you could have an adverse reaction.”
• Confirm the laterality of the surgery. Left knee, right knee, left hip, right hip, left shoulder, right shoulder.
• Mark the surgery site. The surgeon should mark the site before going into the operating room.
• Check for critical information. Make sure all necessary documents and consents have been signed and dated.
• Review the risk assessments associated with every surgery. Has anesthesia assessed the patient preoperatively to determine what potential risks may arise during surgery? In most cases, the anesthesiologist is laying eyes on the patient for the first time in pre-op and those risk assessments need to be done before the patient heads into the OR, says Mr. Taylor.
• Ensure fire safety precautions. The circulating nurse should make sure that everybody on the surgical team has had a fire assessment as part of making sure the operating room is safe. Is there oxygen that will be used in proximity to electrical cautery devices that could cause any type of ignition fire?
• Document the final steps. After the surgery is completed, make sure to document the incision close time and discharge time. Complete the counts on instruments, needles and sponges and ensure that any specimens are labeled correctly.

EMRs streamline safety

The advent of electronic medical records (EMRs) has helped weave the safe surgical checklist into the processes of OR teams everywhere, according to Mr. Taylor. When the World Health Organization first established a safe surgical checklist in the early 2000s, developing those recommendations into practice was a big challenge. There were no EMRs then and checklists were performed by hand.

“What used to be a separate piece of paper years ago that we had to follow to make sure we satisfied every element of the checklist is now part of our standard work list in both preoperative and operative units within the EMRs,” says Mr. Taylor. “We all know that EMRs prompt you through everything, thus everything is a click these days. They’ve been around long enough that they’re ingrained into every nurse’s actual practice.”

Another safety feature is that EMRs cross reference any allergies a patient has with any medications the surgeon may decide to prescribe. For instance, if a patient has an allergy to a penicillin that’s been missed and the doctor tries to order a penicillin-based antibiotic, the EMR automatically flags that.

Multidisciplinary education and cues

MULTIPLE METHODS Facilities should educate the entire OR staff on the surgical safety checklist through scheduled training and education sessions as well as random audits in real time.

Deborah Spratt, MPA, BSN, RN, CNOR, CHL, an independent perioperative consultant from New York, recalls a time when surgical checklists were written in freehand on large white boards displayed in the OR or listed on a piece of paper that only the circulator had access to.

She believes people do better with a visible-to-all consistent cue for the checklist, something that is right in front of them to go through to prevent the never events in the operating room and invasive procedural areas — correct patient and correct site surgery, correct counts, fire risk and allergies. Ms. Spratt adds that the patient should be included in the checklist process/procedure when the procedure is being performed bedside.

“The surgical checklist is a way to confirm and then document, for every patient, that safe practices have happened,” says Ms. Spratt. “You’ve identified the patient; you have a signed consent. You know what the patient is allergic to.”

More recently, she says the checklist has evolved to help providers answer questions about whether they have the correct prosthetics when they’re doing a procedure requiring implants or if they’ve gone over the fire risks.

Buoyed by education

In addition to each facility having a clear checklist policy in place, Ms. Spratt is a big advocate of multidisciplinary education for all team members.

“We still have errors in correct site surgery and surgical specimen mishandling, and OR fires still occur. Those are examples of the kinds of things you should be educating the nursing, anesthesia and surgery staffs on at least once per year,” she says. “The best way for compliance is to educate everybody at the same time and help them understand what the policy is and why you have it.”

Not only should facilities educate staffs through regularly scheduled training and education sessions, but also during audits. Ms. Spratt cited a recent consulting job she had where the facility audited the conversations that staff members had during the time outs to see if they had done everything correctly.

“Auditing is very important when you’re looking at the aggregate, but when you see something while you’re in there checking processes, be sure to stop and say something right then,” she says. “Educate everybody on where they went wrong during their conversation about the items on the checklist.”

An end-of-the-case checklist also ensures that counts, specimens, the patient’s condition, the procedure performed and wound classification are discussed and all staff members are in agreement.

The more reminders, the better

Constitution Surgery Center East does approximately 700 total joints procedures per year, and all patients must attend a total joints education class prior to their surgery. The patient is encouraged to bring along a spouse or someone with them, and the class covers the cornerstone of this story. “Part of that curriculum is discussing the safe surgical checklist with the patient,” says Mr. Taylor. “We do this so they can be prepared for our practice.” It doesn’t hurt that it’s yet another reminder on the ins and outs of the checklist for Constitution’s staff, either.

After all, the more you can talk about a checklist that reinforces accepted safety practices, fosters better communication and prevents unnecessary surgical complications and deaths, the better. OSM