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Safety: Time for a New Surgical Checklist
It starts earlier, ends later, saves time and prevents complications.
Lorne Rosenfield
Publish Date: December 1, 2015   |  Tags:   Patient Safety
checklist items ADVANCED THINKING Staff begin taking care of checklist items long before the day of surgery.

The patient has been wheeled into the OR and put under. The surgeon and OR staff are scrubbed and ready to go. The tools are glistening on the table. All that's left before the first incision is the surgical time out. Is this the right patient? Is this the right body part? Does the patient have any anesthesia issues? (Let's hope not, because we've already administered it.) Do we have the implants? (We'd better, because the patient's already asleep.)

Let's face it. The World Health Organization surgical checklist most of us use, while better than nothing, can be way too little, way too late. In fact, it's mostly just window dressing, designed to cover governmental and accreditation pressures. It may be appropriate and very useful in Third World settings, which is what it was designed for, and where resources are often very limited, but in the First World, it's bare-bones. The fact that medical errors are the third leading cause of death in the United States should be all the proof anyone needs that we need to do better. Much better. And we can.

More detail, less time
In January 2009, the same month the New England Journal of Medicine published the WHO checklist, I published an article (osmag.net/qB8XKu) in the Plastic and Reconstructive Surgery Journal. In it, I detailed a checklist protocol I'd developed — one that starts the first day the patient comes in for a consult — even though the surgery may be months later. From that first visit on, the checklist follows a path, with action items that continue until the day of surgery.

But hold on. Let's take our own time out right here, because usually when I start talking about this, surgeons worry that it sounds like too much work. Well, I have good news: I don't touch the checklist. I created it and I edit it when necessary, but it's my staff members who go through all these steps. They all have parts they're responsible for and they can all access it. The additional work required for nurses or surgeons is nonexistent, because they'd have to be doing all these things anyway.

The point is, you need to be on top of things and accumulating data from the moment the patient first arrives. If a patient has an allergy, we need to make sure we have an alternative. If she has high blood pressure, I need to speak to her doctor. The time to do that isn't a week in advance, because if you change a drug, it may take weeks or even months to stabilize.

It may also take weeks or months to get a patient's records. And when I do, I might find out she had a problem with anesthesia in the past. If so, I'll need to talk to anesthesia long before the day of surgery.

Hospitals and ASCs tend to focus on errors of commission, but not errors of omission. Those typically don't get acknowledged. The checklist helps us make sure everything that needs to happen happens, and that it happens in the right order. By doing so, it actually saves time.

Before and after surgery
Our first real, legitimate pause actually comes one week before the surgery, not on the day of surgery. We meet as a team to discuss the patients scheduled for the following week, review the checklist, and look for any highlighted items we need to remember or address.

We continue down the checklist on the day of surgery until the moment the patient is ready to be moved into the OR. Before the final move, there's another pause. Because if that patient needs to be draped differently or put on the table differently, the time to realize that is before he's in the OR, not after.

In all, we have 92 items in advance of the final pre-surgical pause, which takes place in the OR. And we're not done yet. There are reminders built into the protocol that take place during the surgery. For example, a timer goes off every hour to remind us to update family members. And there's another pause after surgery to discuss any issues with recovery or anesthesia. Ultimately, the protocol continues for another 5 days after surgery.

The ultimate preference card
Once you use my checklist, you may wonder how you could have practiced without it. I've given many lectures, and there are now hundreds, if not thousands, of surgeons using it. I think of it as the ultimate preference card. It comes down to helping people do their jobs the right way, and vastly improving patient safety and satisfaction as a result.

Tailor the Checklist to Reflect Your Specialty

surgical checklist BARE-BONES? The World Health Organization surgical checklist has its limitations, says Dr. Rosenfield.

Maybe the best part about our comprehensive Operating Room Checklist is that it's designed to be a living, breathing document. Nothing is written in stone. My guess is that probably about 90% of it would apply to any surgeon and any surgery, but the other 10% can easily be customized and applied to any specialty. And it can be continually updated.

Several years ago, one of my patients had a MRSA infection during a facelift. I never want to see one of those again, so I talked to a friend who specializes in infectious diseases and we came up with a protocol to add to the checklist. A thousand cases later, we haven't had another.

Preventable complications are practically nonexistent in my practice, and that's because if we ever have a technical or procedural problem in the OR, we immediately update the protocol so it won't happen again.

—Lorne King Rosenfield, MD

Download Dr. Rosenfield's Operating Room Checklist at outpatientsurgery.net/forms.