Surgical safety checklist: Productive, nondisruptive, and the “right thing to do”

Sir,

We read with great interest the article by Oak et al.[1] on the topic of surgical checklist utilization in facilitating operative patient safety. The authors of the manuscript should be congratulated on their contribution to health-care safety. Regardless of the circumstance, operative indications, or the scope of the procedure, it is important to maintain a uniformly standardized approach to the health-care delivery process. Critical to the implementation of any system-wide patient safety measure is the presence of proactive leadership, institutional dialogue, staff training, and built-in avenues for constructive criticism and feedback.[2]

Perhaps the most important contribution of the surgical safety checklist (SSC) is the increased awareness that patient safety spans the entire spectrum of care delivery and involves every member of the surgical team, regardless of the level of experience, operative setting, geographic location, or time of the procedure.[3,4,5,6] The ability to establish and foster the horizontal “team leadership” structure, grounded in shared accountability and personal responsibility, is crucial to the successful implementation of the SSC.[7] Yet, institutional introductions of the surgical checklist are often faced with the criticism that this added safety step creates unnecessary delays in an already busy operating room (OR) schedule, that it does not truly benefit the patient, or that its very presence does not ensure enhanced compliance or greater safety.[8]

The authors of this letter support the notion that the implementation of the SSC must be accompanied by a permanent change in “institutional mindset” and a sustained effort to maintain team focus and a culture of safety.[8] Importantly, communication between hospital leadership and front line practitioners must be open, honest, and constructive in order to obtain the buy-in necessary for the initiative's success. Regarding the concern that SSC increases operative time and introduces unnecessary complexity to an already convoluted process, the authors would like to provide an example from Ohio State University showing that the implementation of the SSC is not disruptive, and that operative times for one of the most commonly performed procedures — laparoscopic cholecystectomy — have not been affected following the introduction of the checklist. More specifically, during the pre-checklist period (2006-2008, average 456 cases per year) the mean time in the OR was 101 min. After the SSC introduction (2009-2012, average 600 cases per year), the mean time in the OR was 100 min. The percentages of cases longer than 90 min were similar at 46% and 52% during the pre- and post-checklist periods, respectively. Subjective observations from St. Luke's University Health Network also support the productive, nondisruptive nature of the SSC as well as its pivotal role in raising and maintaining organizational awareness of a safety culture. This is consistently most evident when the surgeon makes the SSC a priority and leads the “time out” process. When evaluating the SSC in the context of a culture of safety, it makes perfect sense that the entire operative team should review all critical variables jointly, at one time, and without interruptions, thus avoiding inefficient, poorly coordinated, duplicative efforts.

It is the authors’ hope that institutions around the globe embrace the SSC as a critical component of the overall multifaceted approach to enhance patient safety and reduce operative morbidity, mortality, and never events.[5,6,7] We again congratulate Oak et al.[1] on their outstanding contribution to the field of surgical patient safety.