Category Archives: Week 5

Week 5 – Summary: Safer Surgery Checklist

Apologies for the delay in posting the summary of last Sunday’s discussion. A week of nights on call in A&E didn’t leave much time for anything but sleeping.  The summary will be posted as soon as possible and I will tweet a link as soon as I do this. Thank you all for continuing to join in the journal club discussions and I am looking forward to tomorrow night’s discussion already.

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Week 5 – Discussion points: Safer Surgery Checklist

The NEJM paper published in 2009 has had an impact worldwide with the introduction of surgical checklists in over 3000 hospitals. This paper highlighted an important patient safety issue and aimed to tackle this with a relatively simple intervention. The discussion points below are meant to be a broad starting point for the evening, I hope that in particular the methodology of the paper will be discussed in detail.

1. This study ran for less than a year in eight healthcare settings and there have been many criticisms made of the methodology of the paper (see this blogpost & this letters page for examples of the criticisms). Is this adequate enough to support the widespread implementation of the checklist purely based on this paper?

 2. In the discussion of the paper the authors mention the Hawthorn effect as a possible mechanism of improvement, i.e. an improvement in performance due to the subject’s knowledge of being observed. However this has also been raised as a flaw in the study, the fact that the participants knew they were in a trial could have lead to the improvements shown rather than it being due to the checklist. Does this reduce the validity of the study and its findings?

 3. The checklist is a relatively simple intervention, is there a risk that this could become a tick-box exercise rather than being given due care and attention?

 4. In a letter responding to the paper members of NCEPOD stated that they supported the initiative but were concerned that the implied decrease in the perioperative rate of death was unlikely to be as great in the UK as reported in the paper. Does this make the study any less relevant to practice in developed countries?

If there is time I would also like to discuss how the paper is relevant to practice in less developed countries. Thank you to @fidouglas, @amcunningham & @assidens for their help

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Week 5 – Introduction: Safer Surgery Checklist

A Surgical Safety Checklist to Reduce Morbidity and Mortality in a Global Population – Haynes et al for the WHO Safe Surgery Saves Lives Study Group

The paper chosen for this week’s journal club has had an impact on patient safety worldwide: As an F1 during my colorectal surgery job (on the rare occasions I went to theatre) I saw how this paper has changed practice with the implementation of the WHO safe surgery checklist.

In the surgical setting it has been estimated that almost half of all complications are unavoidable. This is a huge patient safety issue. In 2008, the WHO published guidelines to ensure the safety of surgical patients. From this, the authors of the NEJM paper designed a 19 item checklist with the with the aim of reducing surgical complications and its subsequent morbidity and mortality.

The surgical safety checklist is a simple intervention, a checklist that is followed at three key points with the whole surgical team present – before the induction of anaesthesia, before skin incision and before the patient leaves the operating theatre. The primary endpoint of the study was the occurrence of any major complication, including death, during a period of postoperative hospitalisation, up to 30 days (complications were defined as outlined in the American College of Surgeons’ National Surgical Quality Improvement Program).

The trial was run at eight sites in a range of healthcare settings worldwide. Before the checklist was implemented at the trial sites, baseline data, including complication rates, were reported for 3,733 patients at all trial sites. The checklist was then implemented, consecutively enrolling patients over the age of 16 years undergoing non-cardiac surgery. During the pre-checklist period the rate of any complication at all sites was 11%. After the implementation of the checklist this fell to 7% (P<0.001). The total in-hospital rate of death fell from 1.5% to 0.8% (P=0.003). The authors of the paper concluded that:

 Applied on a global basis, this checklist program has the potential to prevent large numbers of deaths and disabling complications, although further study is needed to determine the precise mechanism and durability of the effect in specific settings.

According to the WHO over 3000 hospitals worldwide have now implemented the surgical safety checklist, an impressive figure that shows how research can translate into a world-wide change in practice. Tonight night at 8.00pm BST we will be discussing this paper – a list of discussion points will be posted shortly. I look forward to another interesting and lively debate.

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