Surgical checklist improves mortality—if leadership, surgeons are engaged

Hospitals in South Carolina that implemented a 19-point checklist for surgeons and the operating room team saw a 22 percent reduction in post-surgical deaths, according to a study due to be published in the August issue of Annals of Surgery.

The study is the result of a five-year project involving 14 hospitals which used the World Health Organization’s surgical checklist. The items include tasks like “confirming the patient's identity before induction of anesthesia, marking the site of surgery, confirming any allergies, confirming team members for name and role, and after surgery, confirming instrument counts, name of procedure and specimen labeling.”

The 30-day post-surgical mortality rates at the 14 participating hospitals were then compared to the rest of South Carolina’s hospitals through Dec. 2013. There was no significant difference in the risk-adjusted mortality rates among participants and other hospitals in 2010, but in 2013, participating hospitals had a 22 percent lower 30-day post-surgical mortality (2.84 percent versus 3.71 percent at non-participating hospitals).

“Whereas there are likely differences between these groups of hospitals in their ability to execute on large-scale quality-improvement projects, those differences had not been sufficient to produce a significant difference in post-operative mortality trends before the intervention period. They only diverged following introduction of the checklist program,” wrote Alex Haynes, MD, MPH, assistant professor of surgery at Harvard Medical School and associate director for safe surgery at Ariadne Labs, along with his coauthors.

Haynes and his colleagues noted other studies in Canada and England found little improvement after surgical checklists were made mandatory. The difference in the South Carolina case, they wrote, was a more structured, voluntary implementation process with “broad, sustained participation of both frontline clinicians and hospital leadership,” rather than a regulatory mandate.

“The checklist was specifically designed to better enable team communication and a culture of safety; implementation is unlikely to affect patient outcomes without fostering acceptance of change in attitudes toward patient safety and team behaviors in the operating room,” the researchers wrote.