Reducing errors: Worldwide proof that it's not so hard

There's an encouraging joint announcement coming this afternoon from the World Health Organization and the New England Journal of Medicine. (I've set the timer on this post to publish when the embargo lifts.)

Using a simple but detailed checklist, eight hospitals in a mix of high-income and resource-poor areas were able to reduce their rates of surgical complications by one-third and their rate of death due to surgical complications by almost one-half.

The checklist study was sponsored by the WHO's Safe Surgery Saves Lives campaign. It was headed by surgeon and author Atul Gawande, MD, who is lead author of the NEJM paper and has spoken passionately about checklists as a simple, reliable, reproducible, low-cost intervention that can return extraordinary improvements.

The checklist idea originates in medicine with Dr. Peter Provonost, Johns Hopkins University critical-care researcher and MacArthur "genius" fellow. Gawande wrote a profile of Provonost, and plea for checklist implementation, in the New Yorker in Dec. 2007, and followed that article two weeks later with a New York Times op-ed piece.

The checklist idea has been borrowed from other tech-intensive fields, notably aviation. As a licensed pilot, I can testify that no pilot or crew, no matter how experienced, would ever dare take off without running through a checklist. To believe that you can keep everything you need to do in your head without reference to an external reminder is, in aviation, simply not a credible position. It is considered an absurd display of ego that puts others at unnecessary risk. (For a taste of how aviation looks at medicine's resistance to improvement, see Sir Richard Branson's comments last month.)

In the current study, one hospital in each of eight cities — Toronto, New Delhi, Amman, Auckland, Manila, London, Seattle and Ifakara, Tanzania — agreed to follow a pre-, during- and post-surgery checklist for every noncardiac surgery on patients older than 16. The study group collected data before implementation of the checklist on 3,733 consecutively enrolled patients, and during the checklist implementation, on 3,955 patients.

The checklist is on the WHO website (.pdf in English) along with toolkits for implementation. If you look, you'll see it is very simple. For instance, before anesthesia:

• Patient has confirmed: identity, site, procedure, consent
• Site marked (or marking confirmed not applicable)
• Anaesthesia safety check completed
• Pulse oximeter on patient and functioning
• Does patient have a known allergy? (No/Yes)
• Does patient have a difficult airway/aspiration risk? (No/Yes, and equipment/assistance available)
• Is there a risk of >500ml blood loss (7ml/kg in children)? (No/Yes, and adequate intravenous access and fluids planned)

There are similar short, thorough and noncomplex checklists for before skin incision and before patient leaves the operating room. Amazingly — or not, for those of you who follow the struggle against medical errors — these interventions, simple as they are, were new to most of the study hospitals.

Now, the research team is careful to point out the possible confounders to this study: It introduced changes in systems at the hospitals that may have created independent effects. It may suffer from the Hawthorne effect ("Observation changes the behavior of the observed.") Given that it used consecutively enrolled patients, it may be affected by secular trends at the individual institutions. And it does not track complications post-discharge.

All that being said, I think we can take this as a very potent argument for the adoption of surgical checklists as a component of campaigns to reduce medical errors. And, as Gawande says in the press release that WHO put out this afternoon, a pointer to possible improvements in other specialties as well:

These findings have implications beyond surgery, suggesting that checklists could increase the safety and reliability of care in numerous medical fields... [I]n specialties ranging from cardiac care to pediatric care, they could become as essential in daily medicine as the stethoscope.

The cite on the study is: Haynes, AB, Weiser, TG, Berry, WR et al. Surgical Safety Checklist to Reduce Morbidity and Mortality in a Global Population. N Eng J Med 2009: 260: 491-9. Published ahead of print Jan. 14, 2009.

UPDATE: The full text has been placed online for free.