Application of a modified surgical safety checklist: User beware!

Christopher L. Pysyk 0 1 Jan M. Davies 0 1 J. Neil Armstrong 0 1 0 J. M. Davies, MD J. Neil Armstrong, MD Department of Anesthesia, University of Calgary , Calgary, AB, Canada 1 C. L. Pysyk, MD (&) Department of Anesthesiology , General Campus, The Ottawa Hospital , 501 Smyth Rd., Critical Care Wing 1401, Ottawa , ON K1H 8L6, Canada - 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.5 Read-do5 checklists are also known as call-doresponse6 or verbal action and confirmation7. These checklists are used by one person to identify items to consider or tasks to accomplish, much like a grocery list or a cook book6. Challenge-confirm5 also known as verbal challenge and response7 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 person8. Although reading a list, either silently or aloud, can add to situational awareness,7 there is also the possibility that reading without challenging can lead to omissions or incorrect actions, because people tend to hear what they expect to hear and see what they expect to see8. Thus, regardless of the type of checklist, the ability to prompt dialogue is a key functional property of a checklist. Indeed, Weiser and Berry contend that the verbalization and discussion that ensue through checklist completion are tremendously important, particularly in complex systems like the operating room. It is of interest, therefore, that Morgan et al. achieved\ 10% verbalization of new checklist items, and 21 items were verbalized\ 33% of the time in their study.3 Perhaps this result reflects the relative limitations of perioperative communication skills possessed by healthcare providers. According to Davies and Helmreich,9 recurrent practice of effective communication is essential to integrate and augment the obligatory human factors that influence outcomes in healthcare. Indeed, improved communication skills among operating room team members have been shown through simulation.10 Regardless, few perioperative healthcare workers receive regular structured educational opportunities, such as simulation, to learn strategies that promote effective operating room communication. In addition to the lack of communication training, most operating room personnel (and healthcare providers in general) have not had sufficient (if any) explanation of the theory of, rationale for, and use of checklists. Nor have operating room personnel, for the most part, been trained and socialized in an environment where checklists were an integral part of their practice. In general, expecting a tool, such as the SSC, to augment communication (and thereby improve perioperative outcome) is optimistic when the SSC users are not routinely provided the resources to recognize and minimize communication deficiencies in the operating room. Even if communication training is offered to perioperative team members, bundling other care processes into an already time-critical period may have tested the limits of checklist performance in this context. Effective checklists integrate into the established workflow patterns. The key is balance between brevity and comprehensiveness5 to minimize disruption and achieve the best result. In their report detailing how human factors affect flight-deck checklist performance, Degani & Wiener identify that a checklist must be well grounded within the present day operational environment6. An important component of that environment is the sequence and timing with which checklist items are addressed. For example, the time to complete the pre-takeoff checklist is as an airplane leaves the gate before departure and before reaching the runway hold line, because of the natural nadir in crew workload. This seems analogous to the Briefing before the induction of anesthesia segment of the SSC. As noted by Degani and Wiener, at this point in the departure sequence the probability of successfully accomplishing the first item on the pre-takeoff checklist is highest. However, the probability of accomplishing the subsequent items slowly diminishes as time progresses, since there is more chance for interruptions and distractions to occur6. This may provide some insight to the limited discussion described by Morgan et al., given that their modifications involved additions to the 12th, 13th, and 16th checkboxes of the SSC Briefing section. In a separate study detailing development and validation of the SURgical PAtient Safety System (SURPASS) checklist, de Vries et al. showed that frontline perioperative workers indicated that lack of time was the major factor in over onethird of the instances where a SSC was not completed before major surgery.11 When faced with time and production pressures, decisions to include certain actions (and omit others) when completing a checklist become priority-based.12 In the context of an ambulatory surgical setting, consideration of workflow and time efficiency is perhaps more relevant and influential than in other perioperative environments. By increasing the number of items to be addressed before anesthesia and surgery, the modified SSC used by Morgan et al. may have exceeded the processing limits of the healthcare providers in the ambulatory setting, possibly contributing to the results shown. These results match what has been shown in aviation, where a checklist is simply the physical written document associated with a series of actions, e.g., a check.7 Requiring completion of long and detailed che (...truncated)