A surgical revolution: checklist that could prevent thousands of deaths
An aircraft-style safety test is to be implemented in all British hospitals to reduce the risks of surgery, using a simple checklist that has been proved to save thousands of lives.
Surgeons and nurses will run through the checks before each operation in the same way that pilots check their aircraft before take-off. In Michigan, a similar checklist to reduce hospital infections is estimated to have saved 1,500 lives in the first 18 months.
More than eight million operations were carried out in the UK last year, equivalent to one for every eight people in the population, and there were 129,000 reported incidents in which patients were put at risk, according to the National Patient Safety Agency.
An estimated 2,000 NHS patients die each year as a result of errors in treatment, and an inquiry by the National Audit Office in 2005 concluded that half of all incidents could have been avoided if staff had learnt the lessons of previous mistakes.
Launched today in London and four other cities around the world, the Safer Surgery Checklist is designed to ensure basic precautions have been taken before, during and after every operation. The UK is among the first countries in the world to pledge to implement it, along with Ireland, Jordan and the state of Washington in the US.
It has been described as the biggest innovation in medicine since the stethoscope and research has shown checklists dramatically improve patient care – at virtually no cost.
Surgery is now as routine as childbirth, with most people having two or three operations in their lifetime and its safety is regarded as a public health priority. Although serious errors are rare, a study of 38 surgeons in 14 NHS hospitals published in the British Medical Journal found "most" had experience of operating on the wrong part of the body.
Atul Gawande, the US surgeon and columnist for the New Yorker who is leading the initiative for the World Health Organisation, said: "The complexity of medicine has increased to the point where no one person can ensure it is delivered reliably and accurately. We have been struggling for a tool that can help people reliably deliver safe care. The checklist is turning out to be as important to successful care as the stethoscope. I think you could make the case that it is the biggest innovation since the stethoscope."
The checks are extremely basic and are similar to those used by pilots before take off. They range from confirming the site for surgery (which limb to amputate or kidney to remove) to counting the number of swabs after the operation has been completed (to ensure none have been left inside the patient). Because operating theatres are busy and stressful places, they can be omitted – with potentially lethal consequences for the patient.
The surgery checklist is being tested at St Mary's Hospital, London and seven other hospitals around the world – in the US, Canada, New Zealand, India, Philippines, Tanzania and Jordan – and has already resulted in "substantial reductions in complications and deaths," according to the WHO.
Dr Gawande said: "At the start of the pilot in the eight hospitals, 64 per cent of patients missed at least one check. Putting in the checklist cut the failure rate by half and has reduced deaths and complications, though it is too early to put a figure on it. The remarkable thing was we couldn't tell the first world countries from the developing world countries. This has shown we can do something we have never seen before – improve the safety of surgery on a population basis."
A similar checklist to reduce hospital infections associated with central line catheters, pioneered in Michigan, is estimated to have saved more than 1,500 lives and $175m (£88m) in costs in its first 18 months. The results were reported in the New England Journal of Medicine in 2006 and today Michigan's hospitals still have among the lowest hospital infection rates in the US, Dr Gawande said.
In the UK, a coalition of 13 medical organisations led by the National Patient Safety Agency and including the Royal Colleges of Surgeons, Anaesthetists, Obstetricians and Nurses has pledged to introduce the checklist to every operating theatre in the country. Martin Fletcher, chief executive of the agency, said: "All these professional groups have committed to making this a reality in the UK. We are one of the first countries to get behind it."
In Ireland, Mary Harney, minister for health, has set a target to introduce the checklist in all Irish hospitals by the end of 2009. "She is determined to beat the UK. A bit of neighbourly rivalry is a good thing," Dr Gawande said.
Worldwide, the WHO aims to have the checklist operating in 2,500 hospitals in the most populous countries (with 75 per cent of the world's population) by the end of next year. "We want it to be in every operating room in the world. We know it works and it has virtually no cost. I do five cases a day and the checklist catches at least one thing [that might otherwise have been missed] each day," Dr Gawande said.
Lord Darzi, the health minister whose report on the future of the NHS is to be published next week, chaired the WHO committee that designed the checklist and personally oversaw the pilot study at St Mary's Hospital, where he is professor of surgery.
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