Surgical Checklists in the News!

WHO Proposes Checklist to Reduce Surgery Errors : NPR

A surgical revolution: checklist that could prevent thousands of deaths

Thanks to long-time readers Chet and Andrew for pointing out these similar stories, one from NPR in the U.S. and one from The Independent newspaper in the U.K. (front-page news!)

As a Lean thinker, I love the idea of checklists. They are the Lean concept of “standardized work” in a different wrapper. Standardized work helps ensure quality and consistency of processes – whether in a factory, an airplane cockpit, or a medical setting.

Checklists, when done properly, are written by the people who do the work (just as we would do with standardized work). This isn’t about consultants, mangers, or a single expert dictating the process to others.

Checklists aren’t intended to “turn people into robots.” Checklists and standardized work are a foundation, they cover typical situations, but can’t cover everything. When a truly unique situation comes up, people are expected to utilize their professional judgment – to use their brains. There’s a Toyota expression that says standardized work allows you to avoid hundreds of little decisions so you can make the one major decision that matters.

Checklists aren’t “carved in stone” practices that can never change. As new evidence or practices emerge, checklists and standardized work can be improved – that’s the Lean concept of “kaizen.”

All of these principles were seen back in the story of the cardiac surgeons at Geisinger Health System in Pennsylvania. The surgeons themselves credited the checklists and standardized process for elective bypass surgeries – before, during, and after. The surgeons were able to deviate from the standardized work IF they had a reason they could justify to their peers (not just “because I didn’t want to follow it today”). They improved upon their standard over time… and outcomes for patients improved dramatically.

As I’ve also written about, the work of Dr. Peter Pronovost and Dr. Atul Gawande has proven that checklists are incredibly powerful – preventing infections another preventable patient harm. This probably should be a surprise to Lean thinkers.

So now the World Health Organization is looking to spread these simple, yet powerful, practices around the world.

From NPR:

Since the 1930s, airplane pilots have run through checklists before taking off. Now the World Health Organization wants surgeons all over the globe to use them, too.

Dr. E. Patchen Dellinger, a surgeon at the University of Washington Medical Center in Seattle, says people are surprised when he tells them about the project.

“One of the common reactions is, ‘You mean you weren’t doing that before? Good heavens!'” he says.

Yes, I can understand that reaction! For all of the medical and clinical brilliance in our hospitals, they often have a great deal of opportunity for operational improvements.

Of course there will be resistance to this – as with any change. Again, from NPR:

Gawande says there’s been some resistance to the list. One London surgeon thought it was demeaning “Mickey Mouse stuff” until one day in the operating room.

“Right before the incision [the medical team] took a timeout,” Gawande says, “and when it came to the nurse’s turn to raise any concerns, the nurse asked: ‘Are we really sure we have the right size knee replacement for this patient?'”

Turns out, they didn’t — not anywhere in the hospital. That surgeon now swears by the surgical checklist.

The surgeon now sees the benefit of the checklists – to the patient and to themselves (avoiding a lawsuit — although I don’t know how the legal system treats that in the U.K., compared to here in the U.S.). We have to sell people on the benefits of checklists — not just forcing the method on them and saying “here, do this.” It’s one of my truisms that “people don’t like to be told what to do.” That’s true not only for doctors… but for practically any time of person or role.

From The Independent:

More than eight million operations were carried out in the UK last year, equivalent to one for every eight people in the population, and there were 129,000 reported incidents in which patients were put at risk, according to the National Patient Safety Agency.

An estimated 2,000 NHS patients die each year as a result of errors in treatment, and an inquiry by the National Audit Office in 2005 concluded that half of all incidents could have been avoided if staff had learnt the lessons of previous mistakes.

And more quotes from Gawande:

Atul Gawande, the US surgeon and columnist for the New Yorker who is leading the initiative for the World Health Organisation, said: “The complexity of medicine has increased to the point where no one person can ensure it is delivered reliably and accurately. We have been struggling for a tool that can help people reliably deliver safe care. The checklist is turning out to be as important to successful care as the stethoscope. I think you could make the case that it is the biggest innovation since the stethoscope.”

Dr Gawande said: “At the start of the pilot in the eight hospitals, 64 per cent of patients missed at least one check. Putting in the checklist cut the failure rate by half and has reduced deaths and complications, though it is too early to put a figure on it. The remarkable thing was we couldn’t tell the first world countries from the developing world countries. This has shown we can do something we have never seen before – improve the safety of surgery on a population basis.”

I’m surprised that the error rate was only cut in half. Having the checklist is one thing — we need a management system and culture that ensures that the checklist is used the right way. Zero errors needs to be the goal with checklists.

Worldwide, the WHO aims to have the checklist operating in 2,500 hospitals in the most populous countries (with 75 per cent of the world’s population) by the end of next year.

If you’re reading this and you’re not a hospital employee or leader — if you’re a patient — it’s time to push your local community hospitals to implement this proven method. If not before YOUR surgery, then before the surgery of a neighbor or a loved one. As Pronovost said before, the only thing stopping us from spreading the use of checklists is a lack of desire to do so.

The method is cheap, it’s relatively easy, and it works!


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Mark Graban's passion is creating a better, safer, more cost effective healthcare system for patients and better workplaces for all. Mark is a consultant, author, and speaker in the "Lean healthcare" methodology. He is author of the Shingo Award-winning books Lean Hospitals and Healthcare Kaizen, as well as The Executive Guide to Healthcare Kaizen. His most recent project is an eBook titled Practicing Lean that benefits the Louise H. Batz Patient Safety Foundation, where Mark is a board member. Mark is also the VP of Improvement & Innovation Services for the technology company KaiNexus.

8 Comments on "Surgical Checklists in the News!"

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  1. Andy Wagner says:

    Tonight we celebrate one month since my daughter was born. It was a c-section and I wish I had a recording of the conversation between the anesthesiologist and the nurse. It sounded like a Laurel and Hardy sketch as they discussed who gave my wife the pre-surgery anti-biotic. “I thought you did it.” “I didn’t do it.”
    Later we found the poster proclaiming the hospital’s goal for “Surgical Excellence” that all patients receive anti-biotic 1 hour prior to surgery. My wife got hers about 2 minutes before surgery.
    Hence, the 91% rating.
    Where’s the checklist when you need it?
    Luckily, wife and daughter came through it happy and healthy.
    -Andy

  2. Mark Graban says:

    Nice comment in a Letter to the Editor about the UK aricle:

    “While a front-page feature on “A Surgical Revolution” (“A checklist that could prevent thousands of deaths”, 25 June) is to be welcomed, our research over the past five years into teamwork in surgery shows that the checklist in itself is not really the point. What is important is the quality of its implementation.”

    That’s spot on, for any type of standardized work. Having a document is worthless if people don’t follow it… leaders have to manage the process and follow up properly to make sure the checklist or standardized work is being used, that it’s helping, and that it’s being improved upon.

    LINK (scroll down)

  3. Nickname unavailable says:

    Your wife received the antibiotic within one hour of surgery. This meets the SCIP guideline at the link listed below. No luck or checklist was involved.

  4. Mark Graban says:

    So @nickname_unavailable

    I’m not sure what you’re trying to say.

    1) Checklists aren’t necessary

    2) You’re thankful the right things were done without a checklist being used

  5. trenga says:

    I am not saying or trying to imply either of the two items you write.

    This is what I am saying:

    1.) The initial comment indicates that the author’s wife did not receive the standard of care. With regards to timely administration of an antibiotic, she did.

    2.) A checklist was not used to make this happen.

    If one is trying to make the case for the use of checklists, this anecdote gives little support. This patient received appropriate care without the use of a checklist.

    Let us imagine that the WHO Surgical Safety Checklist (First Edition) had been used in this patient’s care. The check item “has antibiotic prophylaxis been given within the last 60 minutes?” is number 13 of 22 on this particular checklist. This check would be done moments prior to the skin incision. This check would not have averted a similar conversation between the nurse and the anesthesiologist. Nor would it have caused an improved timing for administration of the antibiotic.

    I have not made up my mind about the use of surgical checklists. There are pros and cons. Current medical literature does not support or disprove that the use of a checklist can improve patient safety in a United States hospital.

    I appreciate your initial blogging about the implementation of checklists. I am the surgery section chief (practicing general surgeon) at a hospital that is planning to implement a surgical safety checklist. The initial stages of the planning indicate this is going to come from a “top down” approach under nursing direction. I would like to see a more grassroots approach to this implementation and your comments support this view.

  6. Mark Graban says:

    To the surgeon — thanks for your comments. I realize now you were referring to Andy’s story above in the comments.

    There is a difference between “one hour before” and “within an hour of surgery.”

    Having a checklist right before the surgery is like an inspection. If they hadn’t given the antibiotic 60 minutes before surgery, it’s too late when the checklist is being used. The checklist should guide the process to PREVENT mistakes/omissions rather than catching them at the last minute. So I think we’re saying the same thing, that a checklist at the very last minute might not be the right timing?

    I do share your concerns about the checklist being driven “top down.” That’s not normally the best way to implement lasting change.

    I hope we can have some more interaction about this and other topics.

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