Checklists can help surgical teams perform better during emergencies

When doctors, nurses and other hospital operating room staff follow a written safety checklist to respond when a patient experiences cardiac arrest, severe allergic reaction, bleeding followed by an irregular heart beat or other crisis during surgery, they are nearly 75 percent less likely to miss a critical clinical step, according to a new study funded by the U.S. Department of Health and Human Services' Agency for Healthcare Research and Quality.

While the use of checklists is rapidly becoming a standard of surgical care, the impact of using them during a surgical crisis has been largely untested, according to the study published in the January 17 online and print issue of the New England Journal of Medicine.

"We know that checklists work to improve safety during routine surgery," said AHRQ Director Carolyn M. Clancy, M.D. "Now, we have compelling evidence that checklists also can help surgical teams perform better during surgical emergencies."

Surgical crises are high-risk events that can be life threatening if clinical teams do not respond appropriately. Failure to rescue surgical patients who experience life-threatening complications has been recognized as the biggest source of variability in surgical death rates among hospitals, the study authors noted.

For this randomized controlled trial, investigators simulated multiple operating room crises and assessed the ability of 17 operating room teams from three Boston area hospitals - one teaching hospital and two community hospitals - to adhere to life-saving steps for each simulated crisis.

In half of the crisis scenarios, operating room teams were provided with evidence-based, written checklists. In the other half of crisis scenarios, the teams worked from memory alone. When a checklist was used during a surgical crisis, teams were able to reduce the chances of missing a life-saving step, such as calling for help within 1 minute of a patient experiencing abnormal heart rhythm, by nearly 75 percent, the researchers said.

Examples of simulated surgical emergencies used in the study were air embolism (gas bubbles in the bloodstream), severe allergic reaction, irregular heart rhythms associated with bleeding, or an unexplained drop in blood pressure.

Each surgical team consisted of anesthesia staff, operating room nurses, surgical technologists and a mock surgeon or practicing surgeon.

"For decades, we in surgery have believed that surgical crisis situations are too complex for simple checklists to be helpful. This work shows that assumption is wrong," said Atul Gawande, M.D., senior author of the paper, a surgeon at Brigham and Women's Hospital and professor at the Harvard School of Public Health. "Four years ago, we showed that completing a routine checklist before surgery can substantially reduce the likelihood of a major complication. This new work shows that use of a set of carefully crafted checklists during an operating room crisis also has the potential to markedly improve care and safety."

Hospital staff who participated in the study said the checklists were easy to use, helped them feel more prepared, and that they would use the checklists during actual surgical emergencies. In addition, 97 percent of participants said they would want checklists to be used for them if a crisis occurred during their own surgery.

The practice of using checklists is borrowed from high-risk industries such as aviation and nuclear power, where checklists have been tested in simulated settings and shown to improve performance during unpredictable crisis events.