Airline pilots use a checklist before takeoff to ensure proper procedures are followed. Surgeons make fewer errors during surgery if they use a checklist. (Ralph Orlowski/Getty Images)
Dr. Atul Gawande, associate professor of surgery at Brigham and Women’s Hospital, recently reported this interesting research in The New England Journal of Medicine.
Dr. Gawande analyzed surgical complications and death rates after surgery in hospitals in the United States, Canada, England, New Zealand, Jordan, India, Tanzania, and the Philippines. This was part of the World Organization Safe Surgery Saves Lives campaign.
So how can this study save lives? Dr. Gawande discovered that airline pilots reduced accidents by always ticking off a list of procedures to be completed before takeoff. He believed that surgical errors could be reduced the same way.
On his two-minute checklist, the first item is to confirm the patient’s identity. Then surgeons are sure they’re operating on the right patient. Next, what type of operation is being done, and where the incision will be made to avoid operating on the wrong breast or amputating the wrong leg.
The list also includes the best antibiotic if it’s needed, and what is the best anesthetic for each type of surgery. Lastly, what is the task of each member of the surgical team?
This pilot-inspired approach decreased complications and death by one-third in eight hospitals around the world. Overall, complications decreased from 11.0 percent to 7.0 percent and hospital deaths by an amazing 40 percent.
Today 234 million operations are done every year worldwide. If this checklist were employed in all countries, it would save hundreds of thousands of lives.
Dr. Alex Haynes, another researcher associated with this study, said this checklist would also save $25 billion in complication-related expenses annually in the United States.
Harvard’s Brigham and Women’s Hospital is one of the great hospitals of the world, and I trained there many years ago. But even this hospital is not immune to errors. Dr. Gawande relates how this checklist saved the life of one patient by reminding the surgeon to have enough blood ready for a transfusion.
Dr. Gawande reports that several countries and many U.S. states are now committed to using the surgical checklist in the operating room. All we have to do is look at past surgical records to realize that adding a pilot’s checklist makes good sense.
For instance, The Canadian Medical Protective Association (CMPA) says that in spite of a decade of preaching preventive measures to avoid wrong-side surgery, about 10 cases occur every year in Canada. I couldn’t obtain U.S. figures, but I’d bet it’s about 150 in that country.
In Canada during the period from 1995 to 2005, wrong-side surgery happened 106 times. Each year 6.3 cases involved a lower extremity and 4.3 an upper limb. The most common error was carrying out arthroscopy (looking into the joint with an optical instrument) on the wrong joint. This misfortune happened to 24 patients.
CMPA reports at least one case of total knee replacement was performed on the wrong knee. Hand and foot cases usually involved the wrong hand or an incorrect toe.
Many readers might wonder how, in the name of heaven, such errors could happen. They primarily result from a failure of common sense. In some instances, the patient was anesthetized, the extremity prepared and draped for surgery before the patient was even seen by the surgeon.
In other instances someone other than the operating surgeon marked the extremity that supposedly required surgery, or medical records or X-rays were not available in the operating room. In effect, hospital policy was rarely followed or not at all.
I reported a few years ago that some hospitals have initiated a “time-out” before the incision is made to determine that all i’s have been dotted and t’s crossed. But a checklist makes more sense.
My advice to patients to prevent wrongful amputation is simple. Make the surgeon place his initial on the correct extremity while you’re still awake.
If you know of any wrong-side surgeries, let me know.
Dr. Gifford-Jones is a medical journalist with a private medical practice in Toronto. His Web site is Mydoctor.ca/gifford-jones
