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Winning With Surgical Checklists

What do airline pilots and medical teams have in common? Answer: The use of checklists.

This is not a new idea. It goes back to the 1930s when the U.S. Army Air Corps was testing the B-17 bomber. Due to the number of accidents attributed to “pilot error,” the Corps was on the verge of abandoning the model as “too much plane for one person to fly.” Then they came up with the idea of implementing a pilot’s checklist to make sure all required steps were executed. And the rest, as they say, is history.

Piloting Medical Checklists

From a health care perspective, the use of checklists is a more recent innovation. In 2007, the World Health Organization (WHO) launched the Second Global Patient Safety Challenge, Safe Surgery Saves Lives. An international group of experts, including anesthetists, operating theatre nurses, surgeons, safety experts, and patients was assembled and charged with developing a solution to the problem of unsafe surgery. In 2009, as a result of the international team’s efforts, the WHO Surgical Safety Checklist was released. The same year, Dr. Atul Gawande published “The Checklist Manifesto: How to Get Things Right.” In it, he argues that expanding knowledge leads to increased specialization which leads to greater need for simple solutions to insure access to information. Gawande posits that checklists are just such a solution and are applicable across many fields including medicine, finance, business, and government.

Similar to their use in aviation, in a surgical setting all members of the procedure team have access to the checklist of items that are addressed: before the administration of anesthesia (sign in), before the initial incision (time out), and before the patient leaves the OR (sign out). In addition, team members are encouraged to point out a missed step in real time. This system of checks and balances has obvious benefits: more eyes on the process help decrease the possibility of avoidable human error.

Checklists Address More Than Procedural Issues

What may be less obvious are the results of using checklists on patient and provider satisfaction. Studies from a number of U.S and international facilities show that when patients are aware that checklists are being used, the overall level of their stress decreases and the level of their satisfaction increases. Communication between providers and patients then becomes a key component in higher levels of satisfaction.

When providers invite patients into the process by sharing the information that checklists will be used and by communicating that patient participation will be requested there is a reassuring effect. Pre-operatively, a well-prepared patient will have an understanding of the procedure and outcomes. Similarly, a satisfied patient is more likely to follow plans of care and treatment.

Not only does increased two-way communication and the use of checklists raise satisfaction levels for patients but also for providers. According to a 2015 article (Shapiro, et. al., AORN 2015 Sep; 102(3):290), a study conducted with 35 patients and 52 providers showed 94 percent of patients and 83 percent of providers found a checklist to be beneficial. In their responses, patients observed that checklists “increase medical knowledge, alleviate anxiety and help them prepare for postoperative recovery.” These findings also equate the use of checklists with less human error and fewer discrepancies among the procedure team. In 2014, after a team of nurses and surgeons evaluated discrepancies, wrong site surgeries, near misses, team communication, and patient satisfaction, The Center for Outpatient Surgery in Tinton Falls, New Jersey implemented preoperative, preincision, and postoperative checklists. Following implementation, the data collected for 998 procedures performed identified zero discrepancies between team members, and zero wrong site, wrong side, and wrong patient surgeries (AORN, 2016 Jun; 103(6):617-22).

The AAAHC Standards for risk management (Chapter 5, Subchapter II of the Accreditation Handbook for Ambulatory Health Care) speak directly to this issue of patient safety, stating, “an accreditable organization develops and maintains a program of risk management […] designed to protect the welfare of the organization’s patients [and employees].” Checklists have been shown to advance the intent of this Standard; however, there are caveats.

Using Checklists Optimally

The key, according to the research, is that the successful use of checklists relies heavily on how they are implemented. When members of the surgical team are acting in unison, only then will lists have the ability to positively affect outcomes. This requires that everyone on the surgical team has bought into the importance and effectiveness of checklists as a quality improvement and risk management tool. When even one member is not fully invested, there can be a negative impact on the ability of the staff to act as a team. Per Russ, et al (Annals of Surgery, 258(6), 856-871) “the evidence suggests that safety checklists improve the perceived quality of OR teamwork and communication and reduce observable errors relating to poor team skills […] However, the evidence would also suggest that when used suboptimally or when individuals have not bought in to the process, checklists may conversely have a negative impact on the function of the team.”


Collectively, data and anecdotal evidence suggest that an integrated approach to health care, one focused on teamwork, effective communication, and the use of checklists, has benefits for health care providers and patients. When used optimally, checklists have been connected to improved outcomes, a result that provides benefits to the organization, including decreased risk of litigation and higher scores on patient satisfaction surveys. A win-win for patient and facility.

About the author Brian E. Szumsky is the communications project manager within the AAAHC Marketing and Communication department. He has been with the company since 2015 and has worked with the consulting arm (Healthcare Consultants International) and the AAAHC Institute for Quality Improvement. In addition to managing communications for AAAHC, Szumsky is an adjunct instructor of composition and literature at the college level.



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