To improve surgical safety worldwide, the World Health Organization (WHO) has released a new safety checklist for surgical teams to use in operating rooms, according to a report regarding the Safe Surgery Saves Lives initiative, published online June 25 in The Lancet and also available on the WHO Web site. These WHO guidelines and checklist are the first edition, and they will be finalized for dissemination by late 2008, after completion of evaluation in 8 pilot sites globally.
"Preventable surgical injuries and deaths are now a growing concern," Margaret Chan, MD, director-general of WHO, says in a news release. "Using the Checklist is the best way to reduce surgical errors and improve patient safety."
High mortality and morbidity of major surgical procedures mandate global public health and surveillance measures to improve surgical safety, especially in low-income areas with limited surgical access. Estimates suggest that about half of surgical complications may be preventable.
The Safe Surgery Saves Lives initiative, a collaboration of more than 200 national and international medical societies and ministries of health led by the Harvard School of Public Health, aims to reduce avoidable surgical mortality and morbidity. The newly developed WHO Surgical Safety Checklist provides a set of surgical safety standards applicable to all countries and health settings.
At 8 pilot sites worldwide, preliminary findings from 1000 patients suggest that using the checklist has nearly doubled the likelihood that patients will receive a higher standard of surgical care, with adherence to these standards improving from 36% to 68%, and to nearly 100% in some hospitals. Better adherence has been linked to significant reductions in surgical morbidity and mortality, although final results are not yet available.
The checklist covers 3 phases of a surgical procedure: before anesthesia is induced, before skin incision, and before the patient leaves the operating room. For each phase, a checklist coordinator confirms that the team has completed the designated tasks before the next phase of the operation occurs.
Before induction of anesthesia, key components of the checklist, using the mnemonic "Sign In," are as follows:
Check that the patient has confirmed their identity, the surgical site, and the procedure to be done and that the patient has given informed consent.
The surgical site should be marked, if applicable.
The anesthesia safety check should be completed.
The pulse oximeter should be placed on the patient and functioning.
Check to see if the patient has (1) A known allergy. If so, these should be documented. (2) An anatomically difficult airway to intubate or aspiration risk. If so, additional equipment and assistance should be available. (3) Risk of more than 500-mL blood loss in adults or 7 mL/kg in children. If so, provision should be made for adequate intravenous access and fluids.
Before skin incision, the checklist uses the mnemonic "Time Out" for the following components:
Confirm that all team members have introduced themselves both by name and by their role on the surgical team.
The surgeon, anesthesia professional, and nurse should verbally confirm the patient's identity, surgical site, and procedure to be performed.
Anticipated critical events to be reviewed by the surgeon are any critical or unexpected steps, estimated operative duration, and anticipated blood loss.
Anticipated critical events to be reviewed by the anesthesia team are whether there are any patient-specific concerns.
Anticipated critical events to be reviewed by the nursing team are confirmation of sterility of the tools, supplies, and field (including indicator results); documentation and discussion of any equipment issues or concerns; whether antibiotic prophylaxis has been given within the last 60 minutes, if applicable; and whether essential imaging is displayed, if applicable.
Before the patient leaves the operating room, the checklist uses the mnemonic "Sign Out" for the following components:
The nurse verbally confirms with the team the name of the procedure to be recorded and verifies instrument, sponge, and needle counts, if applicable; labeling for the surgical specimen, including patient name; and whether there are any equipment problems to be addressed.
The surgeon, anesthesia professional, and nurse review the key concerns regarding recovery and management of the specific patient.
The WHO notes that the checklist is not intended to be comprehensive but encourages specific modifications and additions appropriate for each local practice.
"Surgical care has been an essential component of health systems worldwide for more than a century," says checklist coauthor Atul Gawande, MD, MPH, a surgeon and professor at Harvard Medical School in Boston, Massachusetts. "Although there have been major improvements over the last few decades, the quality and safety of surgical care has been dismayingly variable in every part of the world. The Safe Surgery Saves Lives initiative aims to change this by raising the standards that patients anywhere can expect."
Lancet. Published online June 25, 2008.
World Health Organization. Implementation Manual WHO Surgical Safety Checklist (First Edition). Available at: http://www.who.int/patientsafety.
Clinical Context
Worldwide, 234 million major surgical procedures are performed each year, or 1 for every 25 people. Evidence to date suggests that a significant percentage of these are associated with preventable complications and even with death. In industrial countries, rate of major complications ranges from 3% to 16%, and rates of permanent disability or death range from 0.4% to 0.8%.
In the developing world, death rates for major surgery may reach 5% to 10%, with mortality from general anesthesia approaching 1 in 150 in parts of sub-Saharan Africa. Because about half of these complications may be preventable, WHO has created a surgical safety checklist intended to improve surgical safety worldwide.
Study Highlights
About half of surgical complications may be preventable, mandating global public health and surveillance measures to improve surgical safety, especially in underserved areas.
The newly developed WHO Surgical Safety Checklist provides surgical safety standards applicable to all countries and health settings.
At 8 pilot sites worldwide, data from 1000 patients suggest that using the checklist has nearly doubled the likelihood that patients will receive a higher standard of surgical care.
Adherence to these standards improved from 36% to 68% and to nearly 100% in some hospitals.
Preliminary findings suggest that better adherence was linked to significant reductions in surgical complications.
The checklist covers 3 phases of a surgical procedure: before anesthesia is induced ("Sign In"), before skin incision ("Time Out"), and before the patient leaves the operating room ("Sign Out").
Checklist components for each phase are confirmed by a checklist coordinator.
"Sign In" key components include
Check patient identity, site, procedure, and informed consent.
Mark surgical site, if applicable.
Complete anesthesia safety check.
Place functioning pulse oximeter on the patient.
Check to see if the patient has a known allergy (document); a difficult airway or aspiration risk (provide additional equipment and assistance); risk of more than 500-mL blood loss in adults or more than 7 mL/kg in children (provide adequate intravenous access and fluids).
"Time Out" components include
Confirm that all team members have been introduced by name and by their role.
Surgeon, anesthesia professional, and nurse verbally confirm the patient's identity, surgical site, and procedure.
Surgeon reviews any critical or unexpected steps, operative duration, and anticipated blood loss.
Anesthesia team reviews any patient-specific concerns.
Nursing team reviews confirmation of sterility, including indicator results; equipment issues or concerns; whether antibiotic prophylaxis has been given within the last 60 minutes, if applicable; and whether essential imaging is displayed, if applicable.
"Sign Out" components include
Nurse verbally confirms with the team the name of the procedure and verifies instrument, sponge, and needle counts; labeling for surgical specimens, including patient name; and any equipment issues.
Surgeon, anesthesia professional, and nurse review key concerns for patient recovery and management.
The WHO notes that the checklist is not intended to be comprehensive but encourages specific modifications and additions appropriate for each local practice.
Pearls for Practice
About half of surgical complications may be preventable, suggesting the need for global public health and surveillance measures to improve surgical safety, especially in underserved areas. WHO has issued a Surgical Safety Checklist applicable to all countries and health settings. At 8 pilot sites worldwide, preliminary data suggest that using the checklist has nearly doubled the likelihood that patients will receive a higher standard of surgical care. Better adherence has been linked to significant reductions in surgical morbidity and mortality.
The checklist covers 3 phases of a surgical procedure: before anesthesia is induced ("Sign In"), before skin incision ("Time Out"), and before the patient leaves the operating room ("Sign Out"). For each phase, a checklist coordinator confirms that the team has completed the designated tasks before the next phase of the operation occurs.
Reviewed by Ramaz Mitaishvili, MD
