The World Health Organization (WHO) published the WHO Surgical Safety Checklist in 2008 in order to increase the safety of patients undergoing surgery. The checklist serves to remind the surgical team of important items to be performed before and after the surgical procedure in order to reduce adverse events such as surgical site infections or retained instruments. It is one affordable and sustainable tool for reducing deaths from surgery in low and middle income countries. Several studies have shown the checklist to reduce the rate of deaths and surgical complications by as much as one-third in centres where it is used. While the checklist has been widely adopted due to its efficacy in many studies as well as for its simplicity, some hospitals still struggle with implementation due to local customs and to a lack of buy-in from surgical staff.
Background In 2004, the World Health Assembly (WHA) founded the WHO Patient Safety international alliance in order to tackle issues of adverse effects in unsafe healthcare. The Global Initiative for Emergency and Essential Surgical Care and the Guidelines for Essential Trauma Care focused on access and quality. In 2005, WHO Patient Safety began issuing Global Patient Safety Challenges, which bring together teams of specialists in order to put together clinical guidelines and tools for research that address patient safety issues, such as hand washing. In January 2007, an international consultation meeting was held on the second Global Patient Safety Challenge, called Safe Surgery Saves Lives. In 2004, an estimated 187 to 281 million surgeries were performed worldwide, with complications occurring in 3-22% and deaths in 0.4-0.8% of procedures; the death rate in major procedures rose to 5-10% in developing nations. Pointing to the ubiquity of the use of surgery in both the developed and developing world, WHO Patient Safety aimed to meet four main problems: a lack of awareness of the issue; a lack of data on surgical complications; inconsistent use of available safety resources; and increasing complexity of surgical procedures. One of the recommendations of this Global Patient Safety Challenge was the adoption of a checklist for use in surgical procedures. As understood in common language, a checklist is a physical list of tasks to be done, with some measure of marking each item's completion (e.g., a square to be filled with a checkmark). While it is a simple intervention, the checklist has historically been used in many occupations as an organizational and as a safety tool; Atul Gawande, the Safe Surgery Saves Lives program leader, describes the influence that the checklists had on the development of the WHO Surgical Safety Checklist in his 2009 book The Checklist Manifesto. In particular, Gawande praised the impact of pilot checklists in mitigating aviation disasters, tracing their development back to disastrous test flights of the Boeing B-17 Flying Fortress. Because of its increased complexity, an experienced pilot had missed a step in flight, causing a crash; however, test pilots continued to fly the plane, albeit with short checklists that "fit on an index card, with step-by-step checks for takeoff, flight, landing, and taxiing ... the kind of stuff that pilots know how to do." In further testing, the B-17 was flown for 1.8 million miles without further incident; preflight and emergency pilot checklists became a standard safety feature for the industry. Gawande points to how checklists can be applicable in medicine by ensuring that practitioners do not skip important steps in procedures, both in complex, high-stress situations and in seemingly routine ones. In compiling what would become the WHO Surgical Safety Checklist (SSC), the Safe Surgery Saves Lives group set out three goals: simplicity, wide applicability, and measurability. This drew some influence from a prior study that showed a significant decrease in central line infections following the use of a checklist that detailed the basic steps and hygiene requirements (hand-washing; avoidance of the femoral vein; use of chlorhexidine soap; use of sterile PPE and barrier drapes; and daily inspection for possible removal).
Contents The checklist places its nineteen items into three "phases" of a surgical procedure: sign-in (before induction of anesthesia, while the patient is still conscious); time-out (with the surgeon present, before skin incision); and sign-out, based on the Joint Commission's Universal Protocol. At each of these phases, the surgical team members present stop and make sure that the corresponding safety items have been performed (or that there is a valid reason to waive that requirement for the procedure). In order to avoid ambiguity in determining and documenting each step's completion, the WHO recommends that there should be only one clinician (usually a circulating nurse) in charge of marking each item on the checklist.
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