A simple checklist that saves lives

[ Fall 2008 ]

Fighter pilots use checklists to avoid deadly errors. Why not surgeons, too?

So complex was the new B-17 bomber introduced during World War II that a star aviator crashed the mighty aircraft during its demonstration flight. Then the U.S. Army Air Corps introduced its now-legendary safety checklist for pilots and crews to use in the cockpit. The risk of fatal errors plummeted, and checklists became mandatory.

Like piloting a massive warplane, surgery, too, has its risks. But a new checklist unveiled on June 25 by the World Health Organization (WHO) and collaborators at the Harvard School of Public Health should help prevent avoidable deaths and disability in operating rooms worldwide.So reported HSPH’s Atul Gawande at a press conference in Washington, D.C. An associate professor in the School’s Department of Health Policy and Management who also practices general and endocrine surgery in Boston, he spoke as the leader of the WHO’s Safe Surgery Saves Lives initiative, an outgrowth of the World Alliance for Patient Safety.
(UPDATE: New research validates effectiveness of checklist use: Deaths decline by more than 40 percent, complications by one third. Press release, New York Times article)

Staggering Impact
According to estimates published by Gawande, HSPH fellow Thomas Weiser, and other surgeons in The Lancet on the same day the Safe Surgery initiative and checklist were launched, about 234 million major operations take place annually around the world. Millions of patients suffer infections, injuries, and other preventable complications. About 1 million die.

Regions that are poor in resources, technologies, and expertise see higher casualties. In sub-Saharan Africa, death by anesthesia occurs in as many as 1 in 150 operations, as compared to a death rate in the United States of 1 in 200,000.

WHO’s surgical checklist saves lives by ensuring that a surgical team adheres to standard operating procedures. For example: All patients should receive an antibiotic before the incision is made, a practice known to reduce the rate of surgical-site infections by up to 50 percent. But antibiotics aren’t given consistently, even in the most sophisticated health centers, said Gawande, who practices at Brigham and Women’s Hospital, a major teaching affiliate of Harvard Medical School.

Use of the checklist reduces failures to provide six basic surgical standards by half, according to preliminary data from 1,000 patients whom Gawande’s team followed at eight hospitals in developing and industrialized countries.

‘Absurdly Simple’
For more compelling proof of checklists’ value to patient safety, look no further than a pioneering 2006 study by Peter Pronovost, an anesthesiologist and critical care physician at Johns Hopkins University Medical School. Pronovost devised medicine’s first checklist: what Gawande calls “an absurdly simple” tool for safely inserting a central line, or intravenous tubing, into a patient’s chest. This lifeline for delivering medication becomes infected in as many as 4 percent of cases.

Pronovost discovered why. In a study of 100 Michigan hospitals, he found that, 30 percent of the time, surgical teams skipped one of these five essential steps: washing hands; cleaning the site; draping the patient; donning surgical hat, gloves, and gown; and applying a sterile dressing. But after 15 months of using Pronovost’s simple checklist, the hospitals “cut their infection rate from 4 percent of cases to zero, saving 1,500 lives and nearly $200 million,” Gawande told reporters.

At the press conference was Susan Sheridan, leader of the Patients for Patient Safety Program, part of WHO’s World Alliance for Patient Safety. Sheridan said her aim was “to give voice to those who have suffered and those who are now unheard as a result of unsafe surgery.”

She spoke for “Mohammed” of Egypt, whose wife died from blood loss after routine gallbladder surgery; for “Natividad,” a woman in the Philippines, who died after a hysterectomy because two gauze strips were left inside her; and for “Joan,” an American who died in an operating room because anesthesia alarms were turned off and no one noticed her deteriorating condition. The Safe Surgery Saves Lives humble checklist aims to put a stop to tragedies like these.

Patient Safety: Now, a Global Movement
In the United States, the patient safety movement has been around since the mid-1990s, thanks in part to HSPH faculty. The movement’s acknowledged “father” is Lucian Leape, HSPH Adjunct Professor of Health Policy and Management. Leape and two HSPH colleagues-professors David Bates, a pioneer in studying “adverse events” involving patients and medications, and Donald Berwick, founder of the Institute for Health Care Improvement, based in Boston-put a spotlight on safety issues, calling for research and action. A turning point came in 1999, when the Institute of Medicine issued a landmark report, “To Err is Human: Building a Safer Health System,” co-authored by Leape, Berwick, and others. The report identified “faulty systems, processes, and conditions,” not caregivers’ recklessness or negligence, as the chief cause of mistakes or failures to prevent them.

Soon thereafter, WHO’s World Health Assembly resolved that all the world’s citizens deserved safer health systems. As a result, WHO-better known for its efforts to eradicate HIV/AIDS, tuberculosis, and malaria-enlisted Leape, his HSPH collaborators, and other experts, agencies, and ministers of health, to do better at honoring the medical oath to “First, do no harm.”

In 2004, the World Alliance for Patient Safety at WHO was born amid rising concerns that unsafe health care is a global problem. An outgrowth of the Alliance is the WHO’s Safe Surgery Saves Lives initiative, which Gawande now leads.

Ellen Barlow writes about medicine, science, and public health for many Boston-area institutions.

Originally published in Fall 2008