The Surgical Checklist

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Surgical safety checklists (SSCs) are associated with reductions in postoperativemorbidity andmortality and have now achievedwidespread implementation, although thequalityof implementation remainsunclear inmanysettings.1,2 In this issue of JAMA Surgery, Bock and colleagues3 evaluate the effect of introducing an SSC in a single Italian referral hospital on30-and90-dayall-causemortality,30-dayreadmissionrate, and hospital length of stay. Bock et al3 demonstrate a statistically significant decrease inoverall surgicalmortality at90daysafter surgeryand a reduction in hospital length of stay after implementation of anSSC.Mostpreviouspublications thatexaminedsurgicalmortality focusedonthemoretraditional andwidely accepted 30-daypostoperativemortality and readmission rates. Historically, the 30-day outcomes were chosen because of difficulties with long-term follow-up and issueswith attributing death in the 30to 90-daypostoperative period to the primary surgical procedure.3 We commend the authors for choosing to focus on the 90-day postoperative all-cause mortality rate, and we are reassured that they saw a statistically significant decrease. However, we should also considerwhyno statistically significant change in the 30-day postoperative all-cause mortality rates was observed. This finding could be attributable to inherent differences in the population studied, to the case mix, or to insufficient power to detect change related to sample size. This article also highlights the ongoing challenges of checklist implementation and measurement of the impact of the SSC. First, whether SSC performance underwent direct observation during implementation and whether that observation compared with reported performance are unclear. Checklist performance appears to be measured primarily by checking whether a form was completed. Significant discordance between paper checklist completion and actual completion has been described.4 Second, 80% completion was considered the threshold for complete implementation in this study, whereas recent literature supports that full rather than partial checklist completion provides an opportunity for significant improvement of the effect of the SSC on the quality of patient care and surgical safety.5 With more effective implementation and full SSC use in every case, the improvement in outcomes seen could have been even. If the SSC is not used, it cannot help. Although some investigators question the actual impact of checklists, despite the proliferation of evidence regarding improved patient outcomes and quality of care across countries, these arguments fail to acknowledge fully the difficulty of effectively implementingSSCs ina complexhealth system.6 A focus on the systems of care and promotion of a culture of safety at the institutional level is necessary tooptimize checklist implementation and realize its full potential. Effective implementation is critical tomeaningfuluseofSSCs,whichcan lead to maximally improved outcomes.