AORN Journal
Volume 89, Issue 4 , Pages 653-655, April 2009

Checklists and Safety Improvements

Article Outline

 

In a December 2007 article in The New Yorker magazine,1 Atul Gawande, MD, describes a checklist developed by Peter Pronovost, MD, PhD, in 2001. The checklist was introduced into a critical care unit to decrease the incidence of catheter-related bloodstream infections, which are also a concern in surgical patients who require central line insertion. According to Dr Gawande, the steps in Dr Pronovost's checklist included

1)hand washing with soap;

2)using chlorhexidine to cleanse the patient's skin;

3)fully covering the patient with sterile drapes;

4)wearing a hat, mask, sterile gown and gloves; and

5)applying sterile dressings to the catheter insertion site.

Dr Gawande describes the initial resistance by medical and nursing staff members to the use of this procedural tool. Clinicians' objections included concerns that the use of the checklist would delay patient care, that it would not reduce medical error, and that it would annoy physicians and administrators.

Dr Pronovost persisted, and in 2003, the checklist was tested in 103 intensive care units (ICUs). The study's results, published in 2006,2 showed a dramatic reduction in the number of catheter-related infections. Within three months, infections decreased from 2.7 infections to zero infections per 1,000 catheter days. Dr Pronovost's findings demonstrated not only a reduction in central line infections but also that implementation of a specific and deliberate process would improve patient safety.

It is significant that Dr Pronovost and his coauthors noted that “… a checklist was used to ensure adherence to infection control practices [and] providers were stopped (in nonemergency situations) if these practices were not being followed….”2(p2726) These two considerations—use of a checklist and cessation of activity if the steps of the process are not enacted—have become cornerstones of the safety movement.

Back to Article Outline

Surgical Safety Checklists 

For perioperative patients, the introduction of a standardized procedure employing a checklist to prevent wrong site, wrong procedure, and wrong person surgery was generated from a summit convened by the Joint Commission in 2003.3 The resulting Universal Protocol established by the Joint Commission became part of its health care organization accreditation process in 2004.3, 4

More recently, the World Health Organization (WHO) introduced the Surgical Safety Checklist as part of its Safe Surgery Saves Lives program5 to reduce surgical complications on a global scale. The checklist specifies actions in three phases of surgery:

•before induction of anesthesia (ie, Sign In);

•before the skin incision (ie, Time Out); and

•before the patient leaves the OR (ie, Sign Out).5

In a prospective study performed in eight countries between October 2007 and September 2008, researchers using the WHO checklist demonstrated reductions in both the death rate (from 1.5% to 0.8%) and complications rate (from 11% to 7%).6

Although not all errors can be prevented, it is estimated that more than half of surgical complications are preventable.6, 7 Given the substantial evidence demonstrated by Dr Gawande, Dr Pronovost, and others6 that checklists improve safety, why are there not fewer errors?

Back to Article Outline

Barriers to Safe Care 

Some insights come from both media representatives and health care professionals. For example, writing on the Boston Globe web site about an article by Haynes and colleagues6 that discusses the WHO checklist, Liz Kowalczyk8 mentions OR staff members' concerns about wasting time with the checklist when there is pressure to turn over an OR. In interviewing the study's authors, Kowalczyk notes that they “said it takes a strong commitment by hospital leadership to adopt this type of change.”8 When there is greater pressure to focus on turnover time rather than checklist time, there is not only an increased risk for error but also greater potential for frustration among staff members.

Frustration on the part of caregivers can lead to moral distress—the inability to act in an ethical manner because of obstacles within a situation.9 Pauline Chen, MD, writing in the New York Times,10 describes a nurse colleague who felt conflicted because she was unable to express her concerns about patient care without being labeled unprofessional by supervisors or “out of line” by physicians,10 and at the same time she felt, “If I don't say anything … the patient might suffer.”10 Perioperative nurses face barriers to doing the right thing when they are ridiculed for wanting to adhere to a safety checklist and perform a time out or are told that “it's not necessary because I know what I'm doing.” These barriers and other forms of resistance to following established procedures should not be tolerated. Individuals—physicians, nurses, or other personnel—cannot choose to be noncompliant and deviate from established and proven procedures that reduce error. All members of the team are important to patient care, and each member must be able to function in an environment that encourages compliance with practices that promote safe patient care.

Back to Article Outline

Involving All Members of the Team 

Teamwork is a basic tenet of safety. Perhaps what is needed is a redefinition of what constitutes team membership. The importance of administrative support was addressed by Dr Gawande, Haynes et al, and also by Paul Levy, president and chief executive officer of Beth Israel Deaconess Medical Center in Boston, Massachusetts. On his blog of January 15, 2009, Levy writes that when he challenged hospital administrators about using the checklist, “the response [was] silence.”11

Silence is not an option. Active support by health care facility leaders is critical to the successful implementation of a safety checklist. Given their influence in creating and maintaining a culture of safety, health care executives are de facto members of the surgical team. Administrators may not be physically present during a time out, but their support and a “no exceptions” commitment to completing a safety checklist certainly constitute fulfillment of team membership criteria.

Patients are also team members. Perioperative nurses can play an important role by educating administrators and patients, as well as recalcitrant surgical colleagues, about the positive results of using checklists. The benefits include not only better patient outcomes, but also fewer legal liabilities, greater staff satisfaction and reduced staff turnover, and positive financial returns. It seems improbable, but something as simple as a checklist can have profound effects.

Back to Article Outline

References 

  1. Gawande A . The checklist. The New Yorker . http://www.newyorker.com/reporting/2007/12/10/071210fa_fact_gawande December 10, 2007; Accessed February 14, 2009.
  2. Pronovost P , Needham D , Berenholtz S , et al.   An intervention to decrease catheter-related bloodstream infections in the ICU . New Engl J Med . 2006;355(26):2725–2732
  3. Mulloy DF , Hughes RG . Wrong-site surgery: a preventable medical error . In:  Hughes RG editors. Patient Safety and Quality: An Evidence-Based Handbook for Nurses . Vol 2: Rockville, MD: Agency for Healthcare Research and Quality; 2008;p. 2-381–2-395 [AHRQ Publication Number 08-0043] http://www.ahrq.gov/qual/nurseshdbk Accessed February 14, 2009.
  4. Universal Protocol  . The Joint Commission . http://www.jointcommission.org/PatientSafety/UniversalProtocol Accessed February 14, 2009.
  5. World Health Organization  . Surgical Safety Checklist . http://www.who.int/patientsafety/safesurgery/tools_resources/SSSL_Checklist_finalJun08.pdf Accessed February 14, 2009.
  6. Haynes AB , Weiser TG , Berry WR , et al. , Safe Surgery Saves Lives Study Group    A surgical safety checklist to reduce morbidity and mortality in a global population . New Engl J Med . 2009;360(5):491–499 http://content.nejm.org/cgi/content/full/NEJMsa0810119 Epub January 14, 2009; Accessed February 14, 2009.
  7. Institute of Medicine . In:  Kohn LT ,  Corrigan JM ,  Donaldson MS editor. To Err Is Human: Building A Safer Health System . Washington, DC: National Academies Press; 2000;
  8. Kowalczyk L . Safety list cuts surgery deaths. Boston Globe . http://www.boston.com/news/local/massachusetts/articles/2009/01/15/safety_list_cuts_surgery_deaths January 15, 2009; Accessed February 14, 2009.
  9. Elpern EH , Covert B , Kleinpell R . Moral distress of staff nurses in a medical intensive care unit . Am J Crit Care . 2005;14(6):523–530 http://ajcc.aacnjournals.org/cgi/reprint/14/6/523 Accessed February 14, 2009.
  10. Chen PW . When doctors and nurses can't do the right thing. New York Times . http://www.nytimes.com/2009/02/06/health/05chen.html?_r=1&em February 6, 2009; Accessed February 14, 2009.
  11. Levy P . What does it take? In: Running a Hospital [Internet blog] . http://runningahospital.blogspot.com/2009/01/what-does-it-take.html January 15, 2009; Accessed February 14, 2009.

 Editor's note: The Universal Protocol is a trademark of the Joint Commission, Oakbrook Terrace, IL.

PII: S0001-2092(09)00193-8

doi:10.1016/j.aorn.2009.03.005

AORN Journal
Volume 89, Issue 4 , Pages 653-655, April 2009

Article Tools