Theatre checklists and patient safety

Many anaesthetists have witnessed preventable errors in the operating theatre. Wrong site surgery has been the focus of international attention, but still occurs [1]. High profile cases of death resulting from anaesthesia equipment or drug errors receive widespread publicity and result in extensive efforts to prevent their recurrence [2–4]. Less dramatic errors are more common – patients develop wound infections when antibiotics are not administered, or suffer thrombo-embolic complications when prophylaxis is omitted. Although less newsworthy, the complication for the patient may be just as catastrophic. Adverse events during surgery occur in 3–22% of patients [5]. Many are preventable and the theatre team has a crucial role in reducing or eliminating the risks. The Association of Anaesthetists of Great Britain and Ireland (AAGBI) has long promoted the use of checklists to improve patient safety. The equipment checklist, distributed free to every UK hospital and in use internationally, methodically eliminates errors in the anaesthesia machine and breathing circuits [6]. In addition, minimal standards for monitoring in anaesthesia and protocols to manage unanticipated emergency situations have been made available to all AAGBI members, on the topics of anaphylaxis, malignant hyperpyrexia and local anaesthetic toxicity. At a personal level, most of us adopt practices to minimise risk – the way we prepare drugs and the logical sequences which we create quickly alert us to a situation that is diverging from the normal course. However, the reality is that all human beings make mistakes, and in our complex hospital systems we also need to learn the lessons and embrace techniques and technologies developed in other industries that minimise the impact of human error [7]. The airline industry has a well developed safety culture and checklists form an important part of their processes. In airports, travellers are systematically identified, screened and checked, baggage searched and tracked. Pilots and crew are introduced and briefed at the start of a flight; comprehensive checklists are used to ensure the safety of the plane and its controls, including anticipation and management of untoward events that might suddenly occur. All crew members are encouraged to speak up when concerns arise. Checklists ensure that nothing is forgotten, and briefings introduce colleagues and encourage them to function as a part of the team. In peri-operative care in the NHS our systems are less rigorous; although we check that the patient has a valid ticket and catches the correct plane, unlike aircrew we are largely left to our own devices to ensure patient safety in theatre. We retain hierarchical systems and concerns or suggestions raised by junior members of the theatre team may be dismissed or seem unimportant [8, 9]. Peter Provonost and colleagues pioneered the use of a five-point checklist as part of a quality improvement programme to eliminate central venous catheter related infections in the ICU. The nurses were empowered to use the checklist during line insertions to ensure that doctors washed their hands, wore gloves, gown, hat and mask during the procedure, cleaned the patient’s skin with chlorhexidine, draped the patient, and covered the line with an occlusive dressing at the end of the procedure. Line-related infections were almost eliminated at John Hopkins Hospital [10]. The same intervention was then rolled out to 103 ICUs in Michigan and there was a sustained state-wide reduction in infections [11]. A simple checklist ensured that the correct procedure was performed for each patient, every time. Anticipated reservations from doctors and nurses about using a checklist for this procedure were not realised when it was understood that the checklist was for patient safety, and improvement in team working was noted after the introduction of the checklist [10]. Communication failures are recognised as the most common factor underlying adverse events in healthcare. Information may be inaccurate, too late or does not reach the individuals who need to know, leaving issues unresolved until they become critical [12]. Communication failures lead to inefficiency, team tension, waste of resources and cancelled operations. Of concern, there is a strong correlation between minor problems, operative performance and major problems developing during surgery [13]. Improving theatre communication and eliminating minor problems is a cost effective and sustainable way to improve patient safety. In theatre this has been achieved using a checklist to systematically brief all members of the surgical team, with a discussion about the patient, confirmation of procedural details and articulation of clinical concerns [14]. This is an impressive result for discussions that only require 1–6 min to complete for each patient [15]. In 2005 the National Patient Safety Agency (NPSA) developed a checklist with the Royal College of Surgeons to ensure correct site surgery in the NHS [16]. This followed the introduction of a similar mandatory ‘Universal Protocol for Preventing Wrong Site, Wrong Procedure, Wrong Person Surgery’ by the Joint Commission on Accreditation of Healthcare Organizations in the USA [17]. The ‘timeout’ was part of the recommended process. After anaesthesia is induced and the patient is in theatre, the members of the team take time out to confirm correct patient, correct procedure and correct side before skin incision. The concept is straightforward, but in the UK the timeout has Anaesthesia, 2008, 63, pages 921–923 .