Surgery Checklist Reduced Deaths And Complications

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Article Date: 15 Jan 2009 - 2:00 PDT

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An international pilot program that introduced a Surgical Patient Safety Checklist in eight hospitals in eight cities around the world resulted in nearly one third significantly fewer deaths and complications among a diverse adult patient population undergoing non-cardiac surgery.

The findings were written up as an academic paper in the 14 January online issue of the New England Journal of Medicine, NEJM by the pilot program researchers who are part of the World Health Organization (WHO) Safe Surgery Saves Lives Study Group.

In their background information the authors described how surgical complications are common and often preventable, and suggested that a simple checklist might help improve communication among surgical team members and consistency of care, in much the same way as the pre-flight checks that pilots perform.

Around 234 million surgical operations take place globally every year, wrote the authors, explaining that studies done in industrialized countries showed that 3 to 16 per cent of inpatient surgeries have major complications and inpatient deaths at around surgery time occur at a rate of 0.4 to 0.8 per cent. They said surgical teams around the world were also inconsistent in their approach to pre- and post-surgery care, and give the example that despite strong evidence to support the use of antibiotics within one hour before incision to stop possible wound infections this does not always happen.

For the pilot scheme, which took place from October 2007 to September 2008, and formed part of the WHO's Safe Surgery Saves Lives program, the researchers recruited eight hospitals in eight cities around the world: Toronto in Canada; New Delhi in India; Amman in Jordan; Auckland in New Zealand; Manila in the Philippines; Ifakara in Tanzania; London in England; and Seattle in Washington state, USA. Altogether these hospitals represented diverse patient populations and economic contexts.

To establish a baseline for data comparisons, before the introduction of the checklist, the researchers collected data on 3,733 consecutively enrolled patients aged 16 and older who were having non-cardiac surgery. After the checklist was introduced, they then collected data on 3,955 consecutively enrolled patients and compared a range of outcomes between the two groups. The main outcome was the rate of complications and deaths while patients were in hospital up to 30 days after their operation.

The 19-item checklist contained a series of points that the surgical team went through and confirmed they had completed them. For example, at three critical points during a surgical procedure (before anesthesia, just before incision, and before the patient leaves the operating room), a member of the team would verbally confirm that each step of infection control, anesthesia safety and other important considerations (such as confirming the site is marked at the start, or the right number of sponges and instruments are on the table at the the end and therefore none has been left inside the patient).

The results showed that:

• The rate of death was 1.5 per cent before the checklist was introduced and fell to 0.8 per cent afterwards (p=0.003).


• At baseline, 11 per cent of inpatients had complications compared to 7 per cent after the checklist was introduced (p<0.001).

The authors concluded that:

"Implementation of the checklist was associated with concomitant reductions in the rates of death and complications among patients at least 16 years of age who were undergoing noncardiac surgery in a diverse group of hospitals."

"A Surgical Safety Checklist to Reduce Morbidity and Mortality in a Global Population."
Haynes, Alex B., Weiser, Thomas G., Berry, William R., Lipsitz, Stuart R., Breizat, Abdel-Hadi S., Dellinger, E. Patchen, Herbosa, Teodoro, Joseph, Sudhir, Kibatala, Pascience L., Lapitan, Marie Carmela M., Merry, Alan F., Moorthy, Krishna, Reznick, Richard K., Taylor, Bryce, Gawande, Atul A., the Safe Surgery Saves Lives Study Group.
N Engl J MedPublished online 14 January 2009.
DOI: 10.1056/NEJMsa0810119

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Sources: Journal article, University Health Network .

Written by: Catharine Paddock, PhD
Copyright: Medical News Today
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