Checklists are a fundamental part of the airline industry’s safety strategy. Could the medical profession benefit from such an approach?
LAST WEEK’S hearing by a Medical Council Fitness to Practice Committee into the circumstances surrounding a case of “wrong-side” surgery offered worrying insights into practices in operating theatres.
The case, taken against two paediatric surgeons from Our Lady’s Hospital for Sick Children in Crumlin, centred on the removal of the wrong kidney from a six-year-old boy in March 2008. He has been left with a right kidney with 9 per cent functionality.
Evidence was given that the boy’s parents asked hospital staff on at least four occasions to double-check which kidney was to be removed before he was brought to theatre.
Prof Corbally and Dr Paran each gave three undertakings to the fitness-to-practice committee before the case was halted: not to undertake surgery again without reviewing X-rays; not to delegate work to other doctors without ensuring they are prepared and trained; and to prepare a written guide for the medical council within 12 months on the lessons learned from this case.
There is much that medicine can learn from aviation in improving safe practice. The airline industry went through its own difficult learning curve about 30 years ago but emerged with safer operating procedures. Every emergency and “near-miss” investigation is now followed by root-cause analysis, which is, in turn, followed by directives and/or recommendations promulgated throughout the industry. Significantly, the process is founded on a “no-blame” culture.
Taking the comparison with aviation a stage further, could it be that the use of checklists may have reduced the possibility of the tragic events in Crumlin? Or, in a broader context, could the use of checklists by healthcare professionals reduce medical errors and improve safety?
For airline pilots, the use of checklists is a fundamental safety strategy.
It is mandatory that normal and abnormal/emergency checklists are carried in the cockpit. A standard operating procedure ensures that checklists are used for all phases of flight (pre-flight, before start, after start, before take-off, after take-off, climb, cruise, descent, approach, landing, after landing and shutdown).
Much of what commercial pilots do in the course of their work is routine, predictable and straightforward. At times, the work can become tedious, monotonous and even boring.
Normal checklists are designed to ensure that:
- all necessary tasks have been completed;
- the completion of these tasks has been verified by at least two crew members;
- all crew members operate in a standard manner; and
- the risks associated with monotony and boredom are reduced.
In addition, abnormal and emergency checklists are designed to provide crews with a tried and tested methodology for dealing with complex failures, and to minimise the possibility of choosing a wrong option or to make a poor decision as workload and stress increase.
Aviation has refined and tweaked the checklist and its use over many decades. With considerable input from medicine – specifically psychology – concepts such as challenge-and- response, read-and-do and recall- actions have all been incorporated into checklist design and philosophy.
In the United States it has been demonstrated that the use of checklists in the surgical environment has had a positive impact on patient safety.
Research led by Dr Atul Gawande, a surgeon at Boston’s Brigham and Women’s Hospital, has led to the World Health Organisation adopting a checklist approach to safety (see graphic above).
Working with other physicians, Gawande has devised a Safe Surgery Saves Lives checklist. Before a patient is put to sleep, a sign-in must take place, including a formal confirmation of the patient’s identity and the exact surgical site. The next stage is labelled time-out, when the operating team members introduce themselves and their roles before verbally confirming the procedure they are about to perform. Finally comes the sign-out after the operation, when all instruments, sponges and needles are accounted for.
The WHO recommends that a single “checklist co-ordinator” take responsibility for confirming that each member of the surgical team has completed his or her required tasks before the operation begins.
Research into the effectiveness of the 19-step checklist, published in the New England Journal of Medicine, showed that the checklist reduced the rate of major complications by 36 per cent, deaths by 47 per cent, and infections by almost half. When staff were asked whether they would want the checklist done on themselves before an operation, 93 per cent said yes. Gawande says: "Just ticking boxes is not the ultimate goal here; embracing a culture of teamwork and discipline is."
How might this approach have helped prevent the Crumlin tragedy? All on the team would have voiced their agreement that the right operation was being carried out on the correct organ. X-rays would be displayed in theatre and would have confirmed the correct side for incision had been selected. And the late decision to replace one surgeon with another would have triggered a “time-out”, with a reaffirmation of roles and responsibilities among the reconstituted operating team.
Perhaps the most significant lesson aviation offers is the need to eradicate any vestige of surgical hierarchy in the operating theatre. Co-pilots and cabin crew are encouraged to question a captain’s decision in a co-operative cockpit environment. Junior doctors and nurses must be encouraged to do the same in the interests of safe surgery.
IN NUMBERS:Checklist reduced rate of major complications by 36%, deaths by 47% and infections by almost 50%
Capt Carthy is an aviation safety consultant. He and Dr Houston share an interest in seeing how the principles of aviation safety could be applied to healthcare
