US Airways Flight 1529 took off from LaGuardia and wound up in the Hudson River 5 minutes later. All crew members and passengers were safely evacuated. How?

Training, leadership, communications practices, and…safety checklists. Of course, it’s more complicated, but these core components enabled talented personnel to avoid a nearly catastrophic incident.

What if we approached our huddles, briefings, timeouts, and debriefings with the same rigor as the aviation industry? Could we avoid some of the tragedies that happen in our operating rooms (ORs)?

Although personnel are well-trained to deliver medical care, frequently surgical team members feel afraid to speak up when they have concerns. With some slight adjustments—and a little help from technology—OR safety could be enhanced exponentially.

A safety triangle

You can think of OR safety as a triangle with three connected components: clinical training, communication, and checklists. Surgery can’t take place without professionals educated in how to perform procedures and take care of patients. At the same time, operations don’t (or shouldn’t) occur in silence; teams must communicate. And the safety checklist ensures that nothing gets overlooked.

In the triangle, it may look like the safety checklist is unimportant, at least in comparison to the other two points. But the inverse is true. Checklists ensure that basic but critical steps like verifying the patient’s identity and preparing appropriate equipment aren’t missed.

The checklist process helps the standalone experts coalesce into an expert surgical team. It encourages clinicians to talk, coordinate, and accept responsibility. They become advocates and put their skills to use. After all, the person who speaks up when they have a concern is a leader who’s working for the patient, won’t bend to time pressure, and works to ensure that as that patient moves forward on the continuum of care, they have the safest journey possible. The key is actually taking a meaningful “timeout” to follow the checklist.

Too often teams race through or skip over items, not wanting to spend the time or worrying that they shouldn’t speak up due to hierarchical structures. However, the checklist briefings prevent patient injury. According to the World Health Organization, using checklist-based timeouts as a matter of routine can reduce postoperative complications by 30% and save 500,000 lives every year. In practice, it has been found that adherence to checklist-based huddles were observed in just 9% of facilities that performed a wrong site surgery and 75% of facilities that didn’t report one.

The power of a simple tool

A 2019 research review by Haugen and colleagues found that following checklists decreases complications and mortality and improves teamwork and information sharing.

It’s important to recognize, though, that for all that checklists can do, they’re not meant to supplant clinical judgment. They support it. We need highly trained people in ORs and procedure areas, but we also must have guardrails to ensure that we don’t miss anything along the way. Human memory is fallible, and using checklists prevents missing steps.

To get the most out of a safety checklist, you need three things: time, commitment, and persistence. Surgical teams move fast. It’s not uncommon to hear medical personnel brag about how quickly they can tick off items on their checklist. To them, I would say you’re missing the point. It’s not about how fast you can go. Timeouts exist to force folks to communicate and think through everything. It doesn’t mean you have to have a 10-minute conversation.

Commitment refers to sticking with the checklist day-in, day-out for every surgery. In his book The Checklist Manifesto, Dr. Atul Gawande said, “Just ticking boxes is not the ultimate goal here. Embracing a culture of teamwork and discipline is.” The times we stray from the checklist are the times we’re most at risk for failure, so we must stick with it.

Finally, persistence is essential. Teams may not need every item on their checklist, or they could add items based on an issue that’s popped up repeatedly. A checklist should be a living document, and the team should be diligent in making sure it works for them.

Tech-driven precision: Modernizing OR safety

Fortunately, new technologies make these things easier. Applications that integrate into your electronic health record are designed to add or subtract items from a checklist, assign owners, and walk through standard OR procedures. Such applications can engage team members at the right moments to encourage communication and clinical leadership while streamlining the safety process so that nothing is missed. The best part? It’s all just a click away.

Technology makes it so simple to prepare and assess the physical setup of the OR and examine the patient. At the same time, it’s equally adept at prompting required conversations before, during, and after surgery. Well-designed applications can dramatically assist in checklist implementation to set a higher standard of safety.

As ORs across the country become increasingly digital with advanced surgical technologies, safety checklists should be part of the transition. They connect the components necessary for ORs to excel. In fact, safety checklists are becoming so essential that we should start to consider them as another type of insurance—necessary to safeguard patients, providers, and facilities.

Aileen R. Killen, PhD, RN, is the director of perioperative excellence at LiveData, Inc. She has served as anAHA-NPSF patient safety leadership fellow, where she focused on designing operating rooms for patient and staff safety.

References

Gawande A. The Checklist Manifesto: How to Get Things Right. New York City, NY: Metropolitan Books; 2009.

Haugen AS, Sevdalis N, Søfteland E. Impact of the World Health Organization surgical safety checklist on patient safety. Anesthesiology. 2019;131(2):420-5 doi:10.1097/ALN.0000000000002674

Pennsylvania Patient Safety Advisory. Time-out! Wrong-site surgery update. Pennsylvania Patient Safety Authority. 2011;8(2):80-4. patientsafety.pa.gov/ADVISORIES/documents/201106_80.pdf

van Schoten SM, Kop V, de Blok C, et al. Compliance with a time-out procedure intended to prevent wrong surgery in hospitals: Results of a national patient safety programme in the Netherlands. BMJ Open. 2014;4(7):e005075. doi:10.1136/bmjopen-2014-005075

Wyss M, Kolbe M, Grande B. Make a difference: Implementation, quality and effectiveness of the WHO surgical safety checklist—A narrative review. J Thorac Dis. 2023;15(10):5723-35. doi:10.21037/jtd-22-1807