Do surgery checklists really work?

A before and after study at the University of Vermont Medical Center found that a 24-item operating room checklist did not significantly reduce the incidence of any of nine postoperative adverse outcomes.

More than 12,000 cases were studied, and outcomes included: mortality, death among surgical inpatients with serious treatable complications, sepsis, respiratory failure, wound dehiscence, postoperative venous thromboembolic events (VTE), postoperative hemorrhage or hematoma, transfusion reaction and retained foreign body (FB).

After the checklist was established, respiratory failure rates decreased significantly on the initial analysis, but the difference disappeared when the Bonferroni correction* was applied to the dataset.

Why didn’t the checklist work? I have discussed this in previous blog posts here and here. As was true in previous papers of this nature, many of the complications studied — respiratory failure, wound dehiscence, transfusion reaction, postoperative hemorrhage or hematoma — could not have been prevented by a checklist.

The hospital probably had a reasonable VTE prophylaxis protocol before the checklist was adopted in 2012 making it unlikely to have had much of an impact on that problem. Similarly, measures to prevent retained FBs existed well before the OR checklist was invented, and retained FBs occur too infrequently to have resulted in a meaningful difference in this setting.

Another possible explanation for the lack of efficacy of the checklist is that in a university teaching hospital in the United States, most preventable adverse outcomes were already occurring at a low rate.

As part of the study, a survey of operating room personnel including surgeons, anesthesiologists, and nurses found most of the staff understood why the checklist was used and felt it improved patient safety and communication and decreased errors.

The study did not look at either the compliance with checklist use or completeness of the documents. However, the survey revealed that the staff disagreed about the level of completeness of the checklist. About 70 percent of nurses and anesthesiologists believe that the checklist process was rushed compared with only 42% of surgeons. (Rushed? Not us!)

Over 80% of those who completed the survey said they would like to have a checklist used if they were to undergo surgery.

My view of checklists is that they may not prevent complications, but the minute or two spent on going over them is probably worth the effort.

For example, I know a surgeon who found out in the middle of an operation that the type of mesh he wanted to use for a hernia repair was not available. Attention to the checklist would have allowed him to cancel the case or plan from the start to use another product.

So go ahead with your OR checklist, but don’t be surprised if it doesn’t prevent complications.

*An adjustment made to p values when several dependent or independent statistical tests are being performed simultaneously on a single data set.