Jarrod Shapiro, DPM
Practice Perfect Editor
Mountain View
Medical &
Surgical Associates,
Madras, Oregon
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Surgical Checklists — Doing It Better
In a prior Practice Perfect, I made mention of the World Health Organization’s Surgical Safety Checklist. After instituting the Safe Surgery Saves Lives checklist in my hospital and watching how it worked, I wanted to discuss this topic in more detail, and hopefully convince the podiatric community to spearhead the use of this system in your own hospitals. To prevent information overload – and breakdown – I’m going to split the discussion into two parts. Part One below is my attempt to convince you of the importance of this issue. In Part Two, we’ll discuss recent strong work that is revolutionizing our concept of the time out and minimizing patient complications. For those interested in a more detailed discussion of this topic, I refer you to Dr Atul Gawande’s riveting book The Checklist Manifesto.
Perspective on Surgical Complications
First, let’s put the situation in perspective. Currently there are more than 230 million surgeries performed worldwide, which is more than the number of childbirths.1 However, with all these surgeries comes a dark side: surgery is not always safe. In fact, there are approximately seven million disabling complications and one million deaths per year internationally as a result of surgery,1 and half of all surgical complications are avoidable.2,3 In the early 1990’s, a study of 30,195 random charts from New York hospitals found that of 2.6 million charts reviewed for the year 1984, there were 98,609 adverse events, or about 4%.4 Of these complications 48% were associated in some way with a surgical procedure.5 In Australia, a 28 hospital 14000 record review was performed in 2002, which found a 21.9% adverse event rate for surgical admissions.3 Due to these and other studies, we’ve seen national drives to reduce wrong site surgery and prescription errors. However, it remains clear that surgical complication rates can still improve.
Taking a Page from the Airlines
In 1935, the US Army had tasked three airplane manufacturers (one of them Boeing) to present airplanes for military use. Boeing’s plane, the 299, was thought to have the best chance of winning the contract. Then it came time to fly the plane. The 299, flown by the Army’s chief test pilot, took off for the sky. About 300 feet in the air the plane suddenly banked hard, tipped its wing, and crashed, killing two members of the crew, including its pilot. The ensuing investigation determined the cause of the crash was “pilot error” due to the complexity of the airplane. It was “too much plane for one man.” Instead of scrapping the 299 program, the Army did in fact buy 12 planes, but with an additional modification: the use of a checklist at multiple points during the flight. After institution of these checklists, the 299 program flew 1.8 million miles without an incident!6 The 299 was renamed the B-17 Flying Fortress and played a key role in the air campaign during WWII. Today, we see this system of checklists in use throughout the aviation industry.
Medicine: Too Much “Airplane” For One Person
Like the B-17 Flying Fortress, medicine and surgery are simply too complex. Why is it that in the 21st Century, with our modern technologies, incredibly high levels of training for physicians, nurses, and support staff, we still have so many complications? Are physicians doing something wrong?
Not convinced? Between June 2004 – December 2006, the Pennsylvania Patient Safety Advisory found 427 reports with some aspect of wrong site surgery. Of these, almost 20% actually completed a wrong site surgery.7 Now, this didn’t occur 2 decades ago in the early 1990’s. This study was published only 3 years ago—AFTER the Universal Protocol for Wrong Site Surgery became effective.8
Medicine and surgery are very complex undertakings, with multiple often highly routine steps, involving high volumes of patients being seen in very short time periods. The problem really boils down to breaks in memory and attention. Not being machines, humans are prone to lapses in memory, and more commonly, attention, that may result in significant complications. We need a better way to prevent complications among our surgical patients, and this way already exists and has been in use for almost 80 years: checklists.
In part two of our discussion, we’ll discuss the ways in which checklists are revolutionizing safety practices in medicine and surgery. For those interested, you can preview the WHO Surgical Safety Checklist at www.safesurg.org. Best wishes.
REFERENCES:
Correction:
I have to make a small correction in regards to last week’s Practice Perfect Podiatric Parity. In the issue I stated my local hospital does not require podiatrists to be ACLS certified. One of my coworkers kindly reminded me that ACLS certification is in fact required at my hospital. I stand corrected! However, that doesn’t change the fact that out of the last 15 or so hospitals I’ve either trained or worked at ACLS certification was not required. But it should be! Survivability during a major cardiac event is lessened every minute appropriate care is not provided. This behooves all of us who work in the operating room to be ready for the unexpected, so get ACLS certified and continue to move podiatry forward.
Keep writing in with your thoughts and comments or our eTalk discussion forum on PRESENT Podiatry and start or get in on the discussion. Best wishes.
Jarrod Shapiro, DPM
PRESENT Practice Perfect Editor
[email protected]
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