Checklists in operating rooms improve performance during crises

(Press-News.org) Boston – In an airplane crisis—an engine failure, a fire—pilots pull out a checklist to help with their decision-making. But in an operating room crisis—massive bleeding, a patient's heart stops—surgical teams don't. Given the complexity of judgment and circumstances, standard practice is for teams to use memory alone. In a new study published in the January 17 issue of the New England Journal of Medicine, however, researchers at Ariadne Labs, a joint center for health system innovation at Brigham and Women's Hospital and Harvard School of Public Health, have found that teams using checklists have markedly better safety performance. Specifically, the research shows that clinicians provided with checklists in a novel study using advanced simulation of surgical crises were three-fourths less likely to miss key life-saving steps in care.

With many surgical procedures happening simultaneously and around the clock in a hospital setting, crises in operating rooms occur frequently, however, for individual clinicians, these incidents are rare. These high-risk, stressful events require rapid, coordinated care, and failure to rescue surgical patients who have life-threatening complications is the largest source of differences in rates of surgical death between hospitals. Researchers report that the failure rate for performing life-saving processes of care dropped from 23 percent to 6 percent during simulations when checklists were available.

"For decades, we in surgery have believed that surgical crisis situations are too complex for simple checklists to be helpful. This work shows that assumption is wrong." said Atul Gawande, MD, MPH, senior author of the paper, a surgeon at BWH, professor in Health Policy and Management at HSPH, and director of Ariadne Labs. "Four years ago, we showed that completing a routine checklist before surgery can substantially reduce the likelihood of a major complication. This new work shows that use of a set of carefully crafted checklists during an operating room crisis also has the potential to markedly improve care and safety."

For this work, researchers recruited 17 operating room teams, comprised of anesthesia staff, operating room nurses, surgical technologists, and a mock surgeon participant to participate in 106 simulated surgical crisis scenarios in a simulated operating room at the STRATUS Center for Medical Simulation at Brigham and Women's Hospital. Each team was randomized to manage half of the scenarios with a set of crisis checklists and the remaining scenarios from memory alone.

Researchers found that in addition to reporting a reduction in the failure to adhere to life-saving processes of care during simulations when checklists were available, 97 percent of participants indicated that they would want these checklists used if they experienced an intraoperative crisis as a patient

"Given these findings, Brigham and Women's Hospital has now committed to implementing these checklists to increase the safety of our patients and to evaluate the effect they have on care. I would encourage other hospitals and surgical centers to consider doing the same," Gawande said.

Up-to-date checklists and implementation materials can be found at www.projectcheck.org/crisis.

Researchers note that because the study was performed in a simulated operating room, rather than in actual operating rooms with real patients, it is unclear if adherence would improve in a real world scenario. However, high-fidelity simulation has become increasingly accepted in medicine as a means of training and evaluation, and well-structured simulation testing has been shown to efficiently assess the value of safety protocols in other fields.

### This research was funded by the Agency for Healthcare Research and Quality (AHRQ - 1R18 HS018537-01).

Brigham and Women's Hospital (BWH) is a 793-bed nonprofit teaching affiliate of Harvard Medical School and a founding member of Partners HealthCare. BWH has more than 3.5 million annual patient visits, is the largest birthing center in New England and employs more than 15,000 people. The Brigham's medical preeminence dates back to 1832, and today that rich history in clinical care is coupled with its national leadership in patient care, quality improvement and patient safety initiatives, and its dedication to research, innovation, community engagement and educating and training the next generation of health care professionals. Through investigation and discovery conducted at its Biomedical Research Institute (BRI), BWH is an international leader in basic, clinical and translational research on human diseases, involving nearly 1,000 physician-investigators and renowned biomedical scientists and faculty supported by $640 million in funding. BWH continually pushes the boundaries of medicine, including building on its legacy in organ transplantation by performing the first face transplants in the U.S. in 2011. BWH is also home to major landmark epidemiologic population studies, including the Nurses' and Physicians' Health Studies, OurGenes and the Women's Health Initiative. For more information and resources, please visit BWH's online newsroom.

Harvard School of Public Health is dedicated to advancing the public's health through learning, discovery and communication. More than 400 faculty members are engaged in teaching and training the 1,000-plus student body in a broad spectrum of disciplines crucial to the health and well being of individuals and populations around the world. Programs and projects range from the molecular biology of AIDS vaccines to the epidemiology of cancer; from risk analysis to violence prevention; from maternal and children's health to quality of care measurement; from health care management to international health and human rights. For more information on the school visit www.hsph.harvard.edu. END