Right patient? Right limb? Two questions that have almost halved death rate at one hospital
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ALAMY
The latest figures for Britain show that there were 129,419 surgical incidents in 2007
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Surgeons in England and Wales will be ordered today to carry out a safety checklist before every operation they perform, after a study showed it cut surgical deaths and complications by a third.
Described as the biggest clinical innovation in 30 years, the checklist is based on a set of seemingly banal questions but is set to become as essential to daily medicine as the stethoscope. In Britain alone, the new procedure could save hundreds of lives a year and 80,000 complications.
A pilot study run in a London hospital, St Mary's in Paddington, and seven others around the world, has shown that using the checklist cut the death rate following surgery from 1.5 per cent to 0.8 per cent (47 per cent) and the complication rate from 11 per cent to 7 per cent (36 per cent). There was no distinction between hospitals in richer and poorer countries on complications, but richer countries saw a smaller decline in deaths of about a third (though this was not statistically significant).
With an estimated 234 million operations performed yearly around the world, and eight million in Britain – one for every eight people in the population – that translates to millions of lives saved.
The results of the study, organised by the World Health Organisation (WHO), are published in the New England Journal of Medicine. Surgeons and nurses run through a series of basic safety checks before each operation, similar to those made by pilots before take-off. The checks include asking: Is this the right patient? Is this the right limb? Has the patient had the right drugs?
Britain's National Patient Safety Agency (NPSA) issued an alert today to all hospitals and clinics where surgery is performed, setting a deadline for implementation of the checklist by February 2010. Kevin Cleary, the medical director of the NPSA, said: "It is very difficult for the general public to believe that these checks are not being made already. It is about making them every time, and not assuming that someone else is making them."
The latest figures for Britain show that there were 129,419 surgical incidents in 2007 when patients were put at risk, more than 1,000 of which resulted in severe harm and 271 in death. One patient a day was listed for the wrong operation. Sir Liam Donaldson, the Government's chief medical officer, highlighted in his annual report last year 14 cases in which patients undergoing brain surgery had had burr holes drilled on the wrong side of the head. More than one operation a month was carried out on the wrong site in 2007.
Lord Darzi, a Health minister and surgeon at St Mary's who chaired the WHO group that devised the 19-item checklist, said that its implementation across the country was "a dream come true". He added: "It was in front of us – we all travel and it is in every [aircraft] cockpit. Surgery has become vastly more complex and susceptible to errors. Having a system that reminds the whole team of the 19 items is essential. No single individual, however bright, could ensure it happens every time."
About 20,000 patients die each year following surgery, but it is not known how many are preventable. An estimated 2,000 patients die as a result of errors following all forms of treatment and an inquiry by the National Audit Office in 2005 concluded that half could have been avoided if staff had learnt the lessons of previous incidents.
Atul Gawande, an American surgeon and associate professor at the Harvard School of Public Health, who led the study, said work was under way on further checklists for maternity and childbirth (to be published this year), heart disease, pneumonia, HIV and mental health. "It is one of those simple, unbelievably powerful ideas that will have an impact across medicine. Surgeons had assumed that doing well for patients was mostly about their skill. But there is now too much technology and too many patients for one person to deal with."
He added: "When I talk to clinicians, they say: 'we already do this stuff.' The answer is: we are good at doing it most of the time, but we are not good at doing it all the time. We found some members of the team felt they were such low agents, they only felt responsible for their corner. Being allowed to say who they were [one item on the checklist] and hear the surgeon say what he expected made them feel part of the team. When you are not given a voice you turn your brain off."
Peter Walsh, chief executive of the charity Action against Medical Accidents, said there was concern about how surgeons would react to the checklist. "People are on tenterhooks. Some surgeons say that checklists de-professionalise them, turning them into automatons who don't think. But it is only a tool. It has to be used with professional judgement," he argued.
Donald Berwick, the president of the US Institute for Healthcare Improvement, said of the innovation: "I cannot recall a clinical care innovation in the past 30 years that has shown results of the magnitude demonstrated by the surgical checklist."
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Comments
The anaesthesiologist will have done the same and asked if you have any allergies.
It hardly takes much time to observe what we consider to be these common courtesies.
On your way to the theatre, the nurses will already have asked your name to ensure they have the right patient.
None of them seem to need a check list for this!
As a medical student, I think this list is a method for reducing human errors at the minimum possible.
You are only as strong as your weakest link, and i think interventions like this - although they can seem horribly patronising - are aimed at reducing the weak links in the system and safeguarding the patient. No-one "seems to need" a checklist, but i think the evidence speaks for itself.
Bev Hurst
In the UK the use of checklists (double checked) is already standard practice. I don't think we will see the differences you suggest in Britain.
There are a number of hospitals in the UK that are already adding extra measures for tracking surgical instruments or matching patients with the correct medication. For example Wythenshawe Hospital in South Manchester has implemented a bar coding system for its decontamination process to uniquely identify, track and trace its trays containing surgical instruments. Southlands Hospital in Worthing is using bar codes to uniquely identify medicines ? which often have similar packaging and generic names. A simple scan of a bar code can provide peace of mind that patients are receiving the right care and the best service possible. Supplemented with a similar checklist, we would hope to see the figure of 3,000 deaths resulting from patient safety incidents last year alone dramatically reduced. This could be achieved right across the board and not just in the operating theatre.
It is vital that a standard approach is adopted.
Gary Lynch, Chief Executive, GS1 UK
Since NHS is a government service, rarely any surgeon has been sacked for performing outdated surgeries ( very common when I was training) or for incompetency. Caring junior doctors are considered weaklings and weeded out.
How many British surgeon have gone to a patients home to check on his or her condition? How many surgeons call patients at home? As a cardiac surgeon in private practice I know my patients by their first names and I usually call patients at home to check on them and most most of them have become very close friends. I also employ nurses to visit them at home or to call them when required. We have also have mobile labs etc. for blood checks so that the patients are tested at home.
I find the private medical service here is Sri Lanka much better than the UK NHS in many ways. High standard of private cardiac surgery was confirmed by a visiting american team on recently and was published in the papers.
L Dalpadado, FRCS
In my private practice I know almost all patients by name under my care. Even after discharge I call the at home to check on them and sometimes visit them at home if necessary. Now how many UK surgeons do that?. I also employ a nurse to call every patient after discharge to check on them.
In UK NHS most of the leg work is done by junior staff. Some consultants do not even know the names of patients they operate, usually because of the work load. There is a fundamental difference in a government service and private practice. In the NHS patients are just numbers. Surgeon are more interested in the operation and how many can be fitted in a list than actual outcomes or patient care. There is a culture of indifference. Most surgeons were performing open prostatectomies when this technique was considered obsolete in US.
The basic flaw in a government service is that it is very difficult to sack any surgeon ( or any other staff ) for incompetence or indifference . Many out dated, indifferent and rude surgeons ( and other staff) continue to work in the NHS until their retirement
This is not the case in USA or other countries where your success in private practice depend on your results and the service you give to your patient. Ask any British patient who had undergone surgery in USA- they will probably not go back to the NHS if they can afford treatment in US.
This government and I suspect any fovernment.... would rather manipulate the public via the press to pitch patient against doctor rather than sort out those corrupt defence organisations who want us ALL to shut up and go away.