Surgery Checklist Reduces Surgery Deaths
Eight hospitals reduced the number of deaths from surgery by more than 40% by using a simple 19-step pre-surgery checklist.
http://www.medicalnewstoday.com/articles/135487.php
The report in the New England Journal of Medicine says that if all hospitals adopted the checklist, they could save tens of thousands of lives and $20 billion ANNUALLY.
This same article appeared in the January 15 edition of USA TODAY. This article goes on to state that:
- Surgeons are good at making sure they do most of the things most of the time, but not very good at doing all of the things all of the time.
- An operation’s success depends far more on teamwork and communications skills than on an individual surgeon’s skill.
- The checklist takes about 2 minutes to complete.
- It is modeled on checklists used on the aviation industry.
- The checklist has nothing to do with high tech solutions, instead focusing on basic safety measures.
It is almost frustrating to read an article like this. TapRooT® has been teaching these exact principles for 20 years, and now the World Health Organization funds a study that repeats exactly what our TapRooT® investigators would find if they had conducted their own investigation. In fact, after reading the article, I’d swear the author had just attended a TapRooT® course. You can scan through this article and attach the TapRooT® root causes directly to his individual statements.
Luckily, I’m more of an optimist. This study proves that we can make a difference and save lives right now. Even the most basic TapRooT® investigations have the opportunity to fnd and correct these types of relatively simple mistakes. All we have to do is DO IT!
New England Journal of Medicine article:
http://content.nejm.org/cgi/content/full/NEJMsa0810119
Checklist (including video of proper use):
http://www.who.int/patientsafety/safesurgery/en/index.html
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June 7th, 2009 at 2:13 pm
I read this article with interest and although many professionals surgeons implement such practices as standard, it concerns me that many cheaper surgery options are not doing this in all cases.
I also agree that teamwork within a surgeons team is key to a successful procedure - you need to have a team you can trust and depend on.
June 8th, 2009 at 12:01 am
I completely agree. This type of team management should not be reserved to only expensive or high-risk procedures. It stated in the article that the checklist takes only 2 minutes. How can you NOT spend an extra 2 minutes on ALL your procedures?
July 9th, 2009 at 3:26 am
Root Cause Analysis Blog » Blog Archive » Surgery Checklist Reduces Surgery Deaths Hey, nice post, very well written. You should write more about this.
July 9th, 2009 at 4:48 am
I am also agree. In addition to surgical checklist, presurgical and postsurgical checklist should be done. I am a surgeon and always do double check medhod especially in breast surgery. I have my own checklist. First I check, thereafter nurse checks, and i strongly advocate the double check.
July 9th, 2009 at 6:38 am
I’ve found that any industry with significant risk (monetary, injury, environmental, etc) will always benefit from these types of checklists. The cost is normally very low, and the benefit is potentially very high. These checklists are a great example of proactive improvement, avoiding the incidents in the first place and allowing root causes to be discovered and corrected before incidents occur.
I’m a huge fan of post-evolution checklists and meetings. However, very few industries implement these post-evolution “wash-up” meetings, which have the enormous opportunity to discover root causes and lessons learned from the evolution. It is almost a free investigation. The people are already gathered, any problems are fresh in the participants’ minds, and the lessons learned can be immediately promulgated. Using these checklists and meetings after a successful evolution can be key to preventing sentinel events, injuries, and equipment failures in the future.
August 17th, 2009 at 3:25 pm
The problem is you can not just ‘add’ a check list. If you add a list, it will need to be regulated/approved for you to be able to use it. You are in effect creating a new ‘therapy’ in they eyes of the government, and doing so must be controlled. You can have an out of your head checklist, but a written, policy says to follow checklist requires that is be an approved course of action.
August 17th, 2009 at 4:07 pm
Even if a checklist may require more administrative controls, I believe it is still worth the effort in this case. If my options are:
1. Avoid the administrative requirements by memorizing the “checklist”, and having “x” error rate;
Or
2. Going through the hassle of getting the checklist approved, and having a “.6x” error rate;
I think I’d pick #2. Like all options (especially in the medical community), it is a risk vs gain decision. 40% fewer deaths and $20 billion/yr savings seems like a pretty good investment.
All industries have this same decision to make. A cost-benefit analysis is required. Oil refineries can decide not to spend $150,000 on an upgrade, but they may risk lives and huge future costs (see the Texas City BP Refinery explosion). Chemical plants, nuclear power stations, and airlines all have these same high-risk evolutions and regulatory oversight and control, but have implemented checklists to reduce the risk and prevent known problems. Relying on memory has been proven to be error-prone, and any high-risk industry should be taking whatever steps it can to prevent these errors. They have all found that the increased cost (in time, money, effort, etc) is quickly paid back by the results of the decision to remove memory from the equation. I could pay for a lot of checklists for $20 billion/yr!
August 17th, 2009 at 8:31 pm
The government has recently decided that it does NOT require patient permission to test a new “therapy” to create a checklist that covers steps to provide treatment. This repeal of the requirement was covered earlier on this blog.
Thanks
Mark