Chapter 3: Surgical Safety Checklists—Pitfalls and Pearls

INTRODUCTION

• Surgical safety checklists (SSC) can reduce surgical patient harm and improve patient safety culture in the operating suite if utilized and implemented appropriately.

BACKGROUND

The significant volume of global surgical interventions, nearly 200 million, and reports of considerable patient harm related to poor surgical safety processes have motivated endeavors to reduce these events.^1,2 Although surgical events such as wrong site/side/procedure/patient or retained foreign body are rare, malpractice payments totaling upwards of $1 billion are spent in the United States alone to mitigate preventable surgical mistakes.³ The persistence of complications despite standardized practices, such as the Universal Protocol, is alarming as well.¹ SSC have gained momentum as a safety fulcrum developed in hopes of mitigating surgical morbidity and mortality. In industries such as aviation, checklists have been aggressively utilized and now are a standard in airline safety processes. They were first adopted in the 1930s in response to a Boeing airplane crash resulting from the pilot neglecting an important but simple pre-takeoff step.⁴ The enthusiasm for checklist use has filtered into the healthcare environment as well with incorporation into successful safety schemas such as reducing catheter-related bloodstream infections.⁵

THE WORLD HEALTH ORGANIZATION “SAFE SURGERY SAVES LIVES” CHECKLIST

In response to growing concerns about patient safety despite over 15 years of safety-related protocols, the World Health Organization (WHO) initiated the “Safe Surgery Saves Lives” campaign in 2007. WHO Patient Safety, in conglomeration with global experts, subsequently published guidelines in 2008 and 2009 for improving the safety of surgical practice internationally. Born from these guidelines was a 19-item surgical safety checklist meant to address the majority of the 10 safety objectives defined in the guidelines.² The WHO Surgical Safety Checklist works by dividing the operative timeline into three distinct sections (see Figure 3.1).

The “sign-in” denotes the period prior to anesthesia induction where site marking, along with review of patient identifiers, procedure, and site is performed. This period also allots for a review of equipment function and preparation for blood loss, if necessary.

The “time-out” indicates the period immediately prior to incision. It is composed of a brief review of any anticipated surgical concerns and repeated confirmation of the proper patient, procedure, and site.

Lastly, the “sign-out” occurs prior to the patient’s exit from the operating theater. This is comprised of instrument and sponge counts and important details that may affect the patient’s immediate management post-operatively.

Items on the checklist are intended to elicit contribution from all operating room staff as follows; the time-out and ...