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"This IS coming": checklists in the OR

Gawande for CNO 2

Nobody in the operating room knows everything. “It’s the wisdom of the crowd, the beauty of the symphony that ensures success,” said Atul Gawande, MD, MPH, during his General Session “Safer Surgery: Reducing Complications & Disparities” on Monday morning at AORN’s 57th Congress in Denver.

“My basic request of you is that you give [the Surgical Safety Checklist] a try—take it back with you to your hospital. It won’t go well at first but just keep asking how to fix it, how to change it to make it work. The checklist is a lowly, humble, misunderstood tool but it contains a set of values—humility . . . teamwork . . . self discipline . . . ambition . . . to make it work.,” Gawande said.

He is a general surgeon at the Center for Surgery and Public Health at Brigham and Women’s Hospital in Boston and an assistant professor of surgery at Harvard Medical School and the Harvard School of Public Health. He also leads the World Health Organization (WHO)’s Safe Surgery Saves Lives initiative, through with the WHO Surgical Safety checklist was created to confirm information before induction of anesthesia, before skin incision and before the patient leaves the OR.

Despite the early hour, the hall was filled with attendees who listened attentively as this soft-spoken surgeon hit at the heart of their concerns for safety in the OR.

Surgery: a complex process
He began with the story of a three-year-old girl who was revived after being without cardiac function for nearly 90 minutes after drowning. He described the many steps required to save the little girl and the multiple points in the process that were ripe for failure. However, the medical and surgical teams managed to avert trouble at many turns. Even after 90 minutes without oxygen, the little girl not only survived but, today, is a thriving, normal five-year-old, Gawande said. He emphasized that this outcome took hundreds of people making sure that one step after another went right. For instance, if just one person had failed to wash his or her hands, the consequences for this patient might have been catastrophic.

No one ever wants to give up on a three-year-old, but we need to find ways to ensure that everyone can receive this kind of care, he said. “When we think of health care reform, we think of money, or insurance regulations, or litigation as being the problem, but it goes deeper than that,” he explained. “The greatest struggle is the increasing complexities of human fallibility. He explained that we fail because of ignorance, the things we do not know, and ineptitude, having the knowledge but not applying it.”

Development of the surgical safety checklist
The development of the WHO surgical safety checklist began when Gawande was assigned to a World Health Organization project to determine how to reduce deaths in the OR. “It’s not a small matter,” he said, and explained that fifty million surgeries are performed in the United States on 300 million people per year. There is a 3% major complication rate, which on the surface might sound good. But this translates to 150,000 deaths per year in the United States alone as a result of surgical complications, in spite of advanced training and enormous strides in technological development. Projected worldwide, this would mean 7 million people die unnecessarily.

“No other industry faces the complexities that we do in health care, but we can learn from other industries," Gawande said. He described what he called the “B17 moment” for the aviation industry, an airplane crash, after which aviation developed a checklist-system, which has made it one of the safest industries in the world. “We have hit our B17 moment,” said Gawande, “surgery has become too complex for any one individual to ‘fly.’” In response to this realization, Gawande and a team of perioperative experts from around the world developed the WHO surgical safety checklist. The checklist is not a step-by-step list of how to perform surgery; it’s fundamentally about teamwork, Gawande explained. “But initially there is a lot of skepticism. I’ve been thrown out of hospitals all over the world,” he said.

Gawande’s research has shown that about 80% of people using the checklist think it is easy and effective, but on the reverse side, 20% think it won’t work and takes too long. However, when surveyed were asked, “If you were having surgery, would you want the checklist used?” 93 % said yes. Gawande admitted that he was skeptical about checklists. “Working at the one of the premier health care organizations in the world, I didn’t think we needed the checklist, but I implemented it anyway, because I didn’t want to be a hypocrite and, to my embarrassment and surprise, not one week has gone by that the checklist hasn’t detected and prevented an error.” Gawande and his colleagues found that every single hospital that took on the checklist had a reduction in complications.

“The checklist forces a real flattening of the hierarchy,” said Dr Gawande. “The worst thing for people to think is, ‘it’s not my problem,’ because it is our problem! This is coming. It is the standard of care in 24 countries. But, if we make the nurses the police, we fail. If this is about teams, we succeed.”

In Gawande’s most recent book The Checklist Manifesto: How to Get Things Right he explains how applying checklists within the complex world of surgery can reduce error.

Learn more about Atul Gawande here.