Surgical Checklists Less Effective Than Previously Assumed

A new study concludes that the implementation of surgical safety checklists is not associated with significant reductions in operative mortality or complications.

Researchers at the University of Toronto (Canada) surveyed all acute care hospitals in the province of Ontario (Canada) to determine when surgical safety checklists were adopted. Using administrative health data, they then compared operative mortality, rate of surgical complications, length of hospital stay, and rates of hospital readmission and emergency department (ED) visits within 30 days after discharge among patients undergoing a variety of surgical procedures, both before and after adoption of a surgical checklist.

The results showed that during the 3-month periods before and after adoption of a surgical safety checklist, a total of 101 hospitals performed 109,341 and 106,370 procedures, respectively. The adjusted risk of death during a hospital stay or within 30 days after surgery was 0.71% before implementation of a surgical checklist and 0.65% afterward (statistically insignificant). The adjusted risk of surgical complications was 3.86% before implementation and 3.82% afterward (also statistically insignificant). The study was published on March 13, 2014, in the New England Journal of Medicine (NEJM).

“We couldn't identify a measurable improvement with checklists. One problem might be mandating the use of a checklist, as was done in Canada, without getting hospitals to buy into the program,” said lead author David Urbach, MD, a professor of surgery and health policy at the University of Toronto. “It's one thing if hospitals develop these things on their own, where people are motivated and engaged; that can transform a culture and make it more safety-conscious. If it is mandated, it may not achieve the same result.”

The new study stands in stark contrast to a previous study undertaken by the World Health Organization (WHO; Geneva, Switzerland) in 2009 that showed that implementation of a surgical checklist nearly halves the rate of death in surgical patients, from 1.6% to 0.8%. The infection rate at the site of the surgical procedure decreased from 6.2% in the months preceding the checklist introduction to 3.4%. The results of the 2009 study were met with widespread enthusiasm, prompting the UK National Health Service (NHS) to mandate use of surgical safety checklists; Canada followed suit in 2010.

According to the researchers, the high initial death rate in the 2009 study could be due to the fact that a substantial proportion of the patients came from low-income or middle-income countries, where surgical safety checklists could have had a higher impact and provide much greater benefit for patients and hospitals that were already struggling with higher complication rates.

Related Links:
University of Toronto
World Health Organization