Combine Surgery Checklists to Boost Patient Safety and Clinical Outcomes

By Christopher Cheney

Joint use of the World Health Organization Surgical Safety Checklist and the Surgical Patient Safety System (SURPASS) checklist is beneficial for patients, recent research indicates.

Patient safety has been a pressing issue in healthcare since 1999, with the publication of the landmark report To Err Is Human: Building a Safer Health System. Despite two decades of attention, estimates of annual patient deaths due to medical errors have risen steadily to as many as 440,000 lives, a figure that was reported in the Journal of Patient Safety in 2013.

The recent research, which was published in JAMA Surgery, examines information collected from more than 9,000 surgical procedures. The research features three key data points:

  • Joint use of the World Health Organization Surgical Safety Checklist (WHO SCC) and the SURPASS checklist was associated with fewer complications, odds ratio 0.70
  • Joint use of the checklists was associated with fewer reoperations, odds ratio 0.42
  • Joint use of the checklists was associated with fewer hospital readmissions, odds ratio 0.32

“Findings from this study demonstrate that adding the preoperative and postoperative SURPASS checklists to the intraoperative WHO SSC may be clinically advantageous. We found that the joint application of the two surgical checklist systems was associated with reduced in-hospital complications, emergency reoperations, and hospital readmissions,” the researchers wrote.

The reduction in readmissions was likely due to the SURPASS checklist promoting best practices when patients leave a hospital such as medication management and setting recovery expectations, the researchers wrote.

WHO SCC and SURPASS checkpoints

The SURPASS preoperative and postoperative checklist includes the following steps:

  • Admission to ward: Ward doctor checks whether imaging is present and lab work has been done; surgeon checks whether informed consent has been registered and the operation side has been marked; anesthesiologist assesses patient’s condition and orders blood products; nurse makes sure premedication is administered
  • Recovery room or ICU: Surgeon provides instructions about drains, diet, and medication; anesthesiologist provides instructions about ventilation and medication
  • Ward boarding: Surgeon and anesthesiologist specify changes in postoperative instructions
  • Discharge: Ward doctor conducts follow-up, checks medications, and writes discharge letter

The WHO SCC includes the following steps:

  • Before induction of anesthesia: Patient should confirm his or her identity, surgical site, and procedure; the surgical site should be marked; the surgical team should know whether the patient has any allergies
  • Before skin incision: All team members introduce themselves by name and role; essential imaging should be displayed; confirmation of antibiotic prophylaxis within the prior 60 minutes
  • Before patient leaves the operating room: The OR nurse should verbally confirm the name of the procedure, and the surgeon, anesthesiologist, and OR nurse should identify concerns for the recovery and management of the patient

Combining the SURPASS checklist with the WHO SCC

The lead author of the recent research told HealthLeaders that training medical staff on how to use the SURPASS checklist is a key element of the study.

“The primary elements of the training consisted of written and oral information provided to staff groups from the research/implementation group, with daily follow-ups being made in each department by their own staff. During this effort, exemplifying things having been intercepted by checklist use motivated the staff to use the lists daily,” said Anette Storesund, RN, PhD, a consultant in the Department of Research and Development at Haukeland University Hospital in Bergen, Norway.

Combining the surgery checklists has a more significant impact on patient safety and clinical outcomes than adhering to a single checklist, she said. “To get the full benefit from the SURPASS checklist’s use, all of the different checklists need to be utilized. We also found stronger effects when all the checklists for all the key healthcare personnel were used, compared to when some of the checklists had been left out.”

Christopher Cheney is the senior clinical care​ editor at HealthLeaders.