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Taking a moment save lives

A new safety checklist similar to those used by pilots promises to cut surgery rates and complications in Australia’s operating theatres.

Every operation performed at every hospital involves some risk. This is a fact of life. However many complications are preventable, with experts finding a proven way to significantly reduce these incidences – a simple checklist.

Based on a prototype by the World Health Organisation, the surgical checklist was trialled at eight hospitals around the world representing a variety of economic circumstances and a diversity of patients.

The trials found that death rates fell more then 40 per cent, from 1.5 per cent to 0.8 per cent and the rate of complications fell from 11 to 7 per cent after the checklist was introduced.

Federal health minister Nicola Roxon launched the checklist last month, which is a refinement of the WHO prototype, designed to meet Australian and New Zealand clinical conditions. It was developed by the Royal Australasian College of Surgeons, working closely with other specialist medical colleges, the Australian College of Operating Room Nurses, the Australian Commission on Safety and Quality in Health Care, and experts in hospital care from the federal and state health departments.

Urging all hospitals to adopt the checklist as soon as possible, Royal Australian College of Surgeons president, Professor Ian Gough, says it was an essential safeguard that will improve quality of care.

“The checklist is quick and simple to use, and encourages teamwork to make the operating theatre safer. It has been proven to be effective in real operating theatres in a variety of hospitals and countries around the world,” Gough says.

“Its use involves just a few minutes and no extra cost to patients or hospitals. In fact, by reducing complications, this initiative may well save money. More importantly, of course, it will save lives.

“This is something that can and should happen in every hospital.”

The checklist includes things like the proper counting of equipment, ensuring nothing is left inside a patient, the proper labelling of specimens and ensuring correct patient information is collected. It is a single page and used at three crucial points of a surgical procedure: immediately before the administration of anaesthesia, before the first incision, and before the patient is taken from the operating theatre.

Before the first incision, the team of nurses, surgeons and anaesthetists will introduce themselves to each other – a process that aims to encourage members of the team to speak out later if they see something wrong. After the operation a nurse will review, out loud, whether all needles, surgical instruments and sponges have been accounted for and not left inside the patient, and the team will run through its concerns for post-operative recovery and care

Much like a pilot and the team in the cockpit of an aircraft, the surgeons and theatre staff work through the checklist together, ensuring no preventable errors are about to be made, says Gough.

Today 234 million operations are done every year worldwide, according to WHO, with approximately 50 per cent of adverse events in hospitals originating in the operating room. However, the concept of using a brief but comprehensive checklist is surprisingly new to those in surgery, says Dr Atul Gawande, team leader for the development of the checklist.

“Not everyone on the operating teams were happy to try it. But the results were unprecedented, and the teams became strong supporters,” he says.

Although the effect of the intervention was stronger at some sites than at others, Gawande says no single site was responsible for the overall effect, nor was the effect confined to high-income or low-income sites exclusively.

Results of the trial, published earlier this year in the New England Journal of Medicine showed although that the effect of the intervention was stronger at some sites than at others, no single site was responsible for the overall effect. Nor, Gawande says, was the effect confined to high-income or low-income sites exclusively.

“The results indicate that gaps in teamwork and safety practices in surgery are substantial in countries both rich and poor. With the annual global volume of surgery now exceeding even the volume of childbirth, the use of the WHO checklist could reduce deaths and disabilities by millions,” Gawande says.

The effect on death rates was most significant in lower socio economic sites, so surgeons believe results in Australia are unlikely to be as dramatic. But, they do believe it will significantly reduce errors.

New Zealand anaesthetist, Professor Alan Merry was the principal investigator for Auckland, one of the eight pilot sites in the WHO global study. He says while Australia and New Zealand have good safe systems, the checklist was about making it better.

“Anaesthesia and surgery are much safer today than they were even 20 years ago but avoidable mishaps still occur and occasionally these are serious,” Merry says.

“The checklist is a very simple clinical tool that will have an enormous impact on how medical teams prevent these mishaps and their associated complications.”

Gawande says the study’s findings have implications beyond surgery, and that checklists could increase the safety and reliability of care in numerous medical fields.

“The checklists must be short, extremely simple, and carefully tested in the real world. But in specialties ranging from cardiac care to paediatric care, they could become as essential in daily medicine as the stethoscope.”

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