Surgical safety checklist, paired with training, lowers complications after high-risk operations

Surgeon and HSPH student Scott Ellner (center) and colleagues review a safe surgery checklist

February 7, 2013 — Research has shown that using a checklist in operating rooms makes surgery safer and more successful. Now, a new study co-authored by Harvard School of Public Health (HSPH) student and surgeon Scott Ellner found that use of a surgical safety checklist, paired with training to improve communication in the operating room, reduced complications in the 30-day period after high-risk surgery by more than 15%.

“This study was significant because it demonstrated the importance of enhanced communication among all surgical team members to improve patient outcomes,” said Ellner, senior author of the study, who is working toward a master of science degree in health care management, a part-time continuing education program for physicians. He expects to graduate in May 2014.

It’s estimated that only about 25% of U.S. hospitals currently use a surgical safety checklist. And, according to the World Health Organization, while many hospitals routinely perform some pre-surgery checks, few operating teams accomplish them all consistently, even in advanced settings.

In the study by Ellner and colleagues, published in the December 2012 issue of the Journal of the American College of Surgeons, researchers at Saint Francis Hospital and Medical Center in Hartford compared post-operative complications both before and after surgical team members participated in three 60-minute training sessions on improving operating room communication and using a safe surgery checklist. After the training, observers collected data during surgeries to assess whether there were any safety compromising events and whether or not a checklist was used.

Comparing their results to 2,079 historical control cases—in which the rate of adverse events in the 30 days after surgery was 23.6%—the researchers found that when teams participated in training sessions but didn’t use a checklist (246 cases), the rate of adverse events dropped to 15.9%. When teams had training and used a checklist (73 cases), the rate dropped even further, to 8.2%.

Ellner, senior author of the study, is vice chairman of surgery and director of surgical quality at Saint Francis, assistant professor of surgery at the University of Connecticut School of Medicine, and co-founder and chair of the Connecticut Surgical Quality Collaborative. He has focused much of his research on communication and culture change in the health care workplace to improve patient outcomes.

High impact checklist items

The researchers found that certain checklist items, when not followed, were associated with statistically significant changes in outcomes. For instance, there were more adverse post-operative complications—often, surgical site infections—when team members didn’t confirm a patient’s identity, when they didn’t discuss the procedure and the procedure site before surgery, or if all the team members weren’t introduced to each other before surgery. And outcomes were better when nurses left the operating room less frequently—perhaps, the authors speculated, because it reduced the risk of bacterial infection.

Pairing checklist use with training

Ellner said the study shows the importance of pairing the use of a surgical checklist with team training focused on effective communication in the operating room.

“During the training sessions, surgical team members practiced using the checklist, particularly in difficult situations,” Ellner said. In addition, they role-played in high-stress scenarios involving disruptive behavior, missing or malfunctioning equipment, and abrupt changes in the operative plan or procedure.

While there are some checklist items surgical teams might be tempted to skip—such as having everyone introduce themselves before surgery when they already know each other—these are in fact very important, Ellner said.

“Introductions are critical,” he said. “As the surgeon, I think it’s important for members of the team to address me by my first name, and we make sure that everyone else knows each other by their first name. Calling someone by his or her first name elicits trust. In the operating room you want to feel comfortable with your team and know that they will respond appropriately during the most challenging cases.”

Given the small numbers of participants in this pilot study, Ellner said it’s important to follow up with larger studies. He added that his HSPH courses—organizational behavior, operations management, negotiations, and accounting—have been extremely helpful as he and his colleagues work to change operating room culture and improve patient outcomes.

— Karen Feldscher

photo: Joe Driscoll