Hospitals early adopters of surgical checklist

Hospitals early adopters of surgical checklist. Registered nurses Grace Caiado and Christine Paterson, also patient care manager, and Dr. Rajiv Gupta, site chief of surgery at Etobicoke General Hospital, display the surgical safety checklist they adhere to in each of their operating rooms. Starting in April, all hospitals in Ontario will be required to comply to the checklist. Staff photo/ANICE WONG

The 32-point checklist will become compulsory in all Ontario hospitals April 1.

Hospitals will be required to report publicly on surgical checklist compliance twice a year.

"It's probably the single-most important patient-safety initiative to come to surgery in decades," urologist Dr. Rajiv Gupta, Etobicoke General Hospital's (EGH) site chief of surgery, said recently of the checklist EGH adopted in its operating rooms in March 2009.

Trillium Health Centre implemented the checklist at its two hospitals in June 2009.

The surgical safety checklist is based on a global World Health Organization study, begun in October 2008 involving eight pilot hospitals, that adopted a 19-point checklist, including Toronto's University Health Network consisting of Toronto General, Toronto Western and Princess Margaret hospitals.

Post-operative complications and death rates fell by 36 per cent on average among the eight pilot sites, indicated study results published in January 2009 in the New England Journal of Medicine.

Both Etobicoke hospitals adopted the checklist after staff read media reports of the Journal article.

The surgical safety checklist is designed to prevent precisely the kind of errors that made headlines last month after Dr. Barbara Heartwell performed unnecessary mastectomies on two Windsor women. Both women have filed lawsuits.

The "simple, common sense" checklist takes only two minutes, Gupta said.

Just as airline pilots go through a checklist before takeoff, the surgeon, surgical assistant, nurses and anesthetist verbally run through the surgical checklist.

Pre-anesthesia, the surgical team ensures it has the right patient, correct procedure, and blood type and allergies are confirmed.

Prior to the incision, injection of antibiotics is confirmed, and any anticipated critical events discussed.

Post-op, the team debriefs about any concerns for recovery and patient management, and conducts instrument, sponge and needle counts.

"It's a team approach," Gupta said, noting the patient is also involved. "Any individual in the room can at any time, hopefully, feel that he or she can speak up and say, 'Wait a minute. Something's wrong.' The idea is to flatten the pyramid. Put everyone on an equal playing field."

Outcomes involve shared responsibility and liability, Gupta suggested, as well as increased surgical team morale.

Annually, approximately 11,000 in- and out-patient surgeries take place at EGH.

Etobicoke General's checklist, laminated and posted in each OR, has made "good catches" that include: an incorrect limb marked for orthopedic surgery, a pathology specimen lost in the drapes, mislabeled radiology reports, as well as better compliance with use of antibiotics to decrease the risk of post-operative wound infections and for prosthetic insertions.

"There will never be zero errors. I recognize it's unattainable. But it's a goal we should strive for," Gupta said.

The Ontario Hospital Association asked Gupta, patient care manager Christine Paterson, RN and Dipali Patel, clinical nurse education for Etobicoke General's OR to help other hospitals implement the list after they presented their implementation results.

Gupta conducts teleconferences to Ontario hospitals and Web seminars to hospitals across Canada to help them implement the list.

Medical professionals from Oakville-Trafalgar Memorial Hospital, Milton District Hospital, Georgetown Hospital and North York General Hospital came to Etobicoke General to learn what they do and how they do it.

"I say, 'It's not you as the driver putting the seatbelt on because you're the healthcare provider. It's the patient. It's your child in the backseat. Would you dare put your infant child in the backseat and go on the highway without a proper childseat installed? No way.'"

Trillium Health Centre adopted the surgical safety checklist in ORs at its Toronto West hospital near Sherway Gardens and in its Mississauga hospital last year.

Trillium operates the largest free-standing surgery centre in North America at its West Toronto site in Etobicoke.

Both hospital spokespersons stressed "surgical time out" checks were in place in their hospitals in recent years. The surgical safety checklist formalizes the process, they said, and makes it interdisciplinary.

"One of the biggest revelations of the implementation of this checklist is that we were always doing some type of checklist, but we were doing it in silos," said Nancy Butterworth, RN and Trillium's clinical educator for its OR, cardiovascular OR and Post-Anesthesia Care Unit. "To see the research from the WHO and the impact of just having the interdisciplinary communication of what should have been done and confirming that those things were done was very eye-opening. The impact of having that additional safety net is overwhelming to recognize."

Medical staff from Trillium's labour and delivery and radiology departments have since expressed interest in adopting a similar checklist, Butterworth said.

A September 2009 audit of checklist "good catches" in Trillium's Mississauga hospital included: a completed history for an emergency surgical patient, availability of additional units of blood for another patient, and a third who self-identified allergies that were not noted in an earlier office interview with the surgeon.

"Our goal is patient safety, to ensure our patients receive the highest quality of care based on the evidence out there," Butterworth said. "We have a responsibility to provide that to our patients."