Application of a modified surgical safety checklist: User beware!

Abstract

Use of the Surgical Safety Checklist (SSC) has blossomed since a landmark publication showed improved morbidity and mortality with its implementation. Parallel to increasing use of the SSC is a growing body of research investigating the effect of the SSC on the safety of care delivered. Nevertheless, at least one study shows an inconsistent degree of effect on outcomes. Others have investigated the impact of modifications of the SSC tailored to different clinical settings, as Morgan et al. show in their study, ‘‘Surgical safety checklist: implementation in an ambulatory surgical facility’’, in this issue of the Journal. The purpose of this study was ‘‘to add ambulatory carespecific items to the checklist, to assess adherence to safety checklist items, and to examine the impact of the SSC on safety attitudes and important patient outcomes’’ – all in an ambulatory surgical centre. On first thought, this is a logical concept, given that more and more procedures are being carried out on an ambulatory basis. What distinguishes this study from others that have investigated the impact of a SSC on various outcomes is the ambulatory scope and application of a modified SSC to this unique clinical environment. The primary outcome of the study consisted of two end points obtained through telephone interviews with patients on postoperative day one: (1) severity of pain (assessed on a scale of 1-10) and (2) incidence of postdischarge nausea/vomiting (PDNV). Secondary outcomes included the ‘‘incidence of perioperative antibiotic timing, use of regional anesthesia/ analgesia, length of stay, and the number of hospital admissions’’. Despite engaging a multidisciplinary team (consisting of nurses, surgeons, and anesthesiologists) to identify ambulatory-specific factors for inclusion on a modified SSC, clinically relevant differences in the primary and secondary outcomes were not achieved. Why did this occur? The authors identify several possible reasons for lack of effect with their well-intentioned ambulatory SSC: too many additions creating an unwieldy tool, issues with perceived importance of the new items by perioperative staff using the modified SSC, and low rates of overall checklist completion. Though many possible explanations exist, one must ultimately question if the SSC — with its recognized effect on mortality — can be expected to influence ambulatory outcomes like pain scores and PDNV. In their recent review of how and why checklists work, Weiser and Berry detail two main types of checklists. ‘‘Read-do’’ checklists are also known as ‘‘call-doresponse’’ or ‘‘verbal action and confirmation’’. These checklists are used by one person to identify ‘‘items to consider or tasks to accomplish’’, much like a grocery list or a ‘‘cook book’’. ‘‘Challenge-confirm’’ — also known as ‘‘verbal challenge and response’’ — checklists are generally more formalized and are used by two or more individuals, for example, a flight captain and co-pilot completing pre-takeoff checks. With this type of checklist, the reader of the checklist ‘‘challenges’’ another team member to ‘‘confirm’’ completion of each task in a communication format that is scripted to minimize confusion and maximize efficiency. Many checklists in industry and healthcare are a combination of ‘‘read-do’’ and ‘‘challenge-confirm’’, but use of a checklist (like the SSC) should be much more than simply ‘‘double checking’’, which has been described as the use of ‘‘one fallible person (to) monitor the work of another imperfect C. L. Pysyk, MD (&) Department of Anesthesiology, General Campus, The Ottawa Hospital, 501 Smyth Rd., Critical Care Wing 1401, Ottawa, ON K1H 8L6, Canada e-mail: cpysyk@toh.on.ca