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AHS Safe Surgery Checklist User Manual

1. Indicators Performed 7572 Completed iN Sponge Count Oral Confirmation N 7688 of Patient s Identity and Operative Site Prophylactic Antibiotics Given Appropriately N 6802 m g Ti 3 5 F 3 a 2 fr SG T Goas f EBL 500 ml N a QO g ET ow Oo H Pulse Oximeter Used N 7688 Performed N 7688 Evaluation Objective Airway Site No Patients Enrolled JANUARY 29 2009 60 minutes before an incision was rade Sponge counts were considered to be indicated in all cases in which an incision was made P values are shown for the comparison of the total Prophylactic antibiotics were considered to be indicated for all cases in which an incision was made through an uncontaminated field and appropriately administered when given within values before and after checklist irmplernentation calculated by means of the chi square test EBL denotes estimated blood loss and IV intravenous Downloaded from www nejm org on February 20 2009 For personal use only No other uses without permission Copyright 2009 Massachusetts Medical Society All rights reserved www albertahealthservices ca Alberta Health Mm Services AHS Safe Surgery Checklist Manual 35 The NEW ENGLAND JOURNAL of MEDICINE with postintervention data and the consecutive recruitment of the two groups of patients from the same operating rooms at the sam
2. Weight Kg recorded on chart Anesthesia safety and equipment check completed Difficult airway aspiration risk Applicable equipment assistance available Patient positioning and support confirmed Relevant and special equipment confirmed and in room Prosthesis Warming devices Loaner instrument Relevant tests completed and checked Laboratory Pregnancy Crossmatch Type and Screen Radiology Time Out Allteam members have introduced themselves by name and role Surgeon Anesthesiologist and Nurse have verbally confirmed Patient Procedure Site Anticipated critical events Surgeon review Critical or unexpected steps Procedure duration Risk of gt S00mL 7mL Kg in Children blood loss Anesthesiologist review Patient specific concems Adequate intravenous access and fluid planned Nursing review Sterility issues _ Equipment issues Applicable medication concerns Antibiotic prophylaxis given within last 60 minutes Thromboprophylaxis VTE ordered Anticoagulant Mechanical Other specific medication concems Essential imaging displayed Before Patient Leaves Operating Room Debri sid Surgical team have verbally confirmed Name of the procedure Applicable sponge and instrument counts Specimen labeling and handling Equipment problems addressed Surgical team have reviewed recovery p
3. Turkey Sayek Sydney Australia B Barraclough REFERENCES 1 Weer TG Regenbogen SE Thomp based on available data Lancet 2008 372 mortality who when where and why son KO etal An estimation of the global 139 44 Lancet 2015 366 1189 200 volume of surgery a modelling strategy 2 Ronsmans C Graham WJ Maternal 3 Debas HT Gosselin R MeCord C 498 N ENGL J MED 405 NEJM ORG JANUART 29 2009 Downloaded from www nejm org on February 20 2009 For personal use only No other uses without permission Copyright 2009 Massachusetts Medical Society All rights reserved www albertahealthservices ca AHS Safe Surgery Checklist Manual 36 E Alberta Health Mm Services Thind A Surgery In Jamison DT Bre man IG Measham AR etal eds Disease control priorities in developing countries ind ed Disease Control Priorities Project Washington OC International Bank for Reconstruction and Development World Bank 2006 1245 60 4 Gawande AA Thomas EJ Zinner MI Brennan TA The incidence and nature of surgical adverse events in Colorado and Utah in 1992 Surgery 1999 126 66 75 5 Kable AK Gibberd RW Spigelman AD Adverse events in surgical patients in Australia Int J Qual Health Care 2004 14 269 76 6 Bickler amp W Sanno Duanda B Epide nuolopy of paediatric surgical admissions to a government referral hospital in the Gambia Bull World Health Organ 2000 78 1330 6 7 Yii MK Ng KJ Risk adjust
4. imme diately before incision and before the patient is taken out of the operating room The checklist was translated into local language when appropriate and was adjusted to fit into the flow of care at each institution The local study team tntroduced the checklist to operating room staff using lec tures written materials or direct guidance The primary investigators also participated in the train ing by distributing a recorded video to the study sites participating tn a teleconference with each local study team and making a visit to each site The checklist was introduced to the study rooms over a period of 1 week to 1 month Data collection resumed during the first week of checklist use No of No of Site Location Beds Operating Rooms Type Prince Harnzah Hospital St Stephen s Hospital University of Washington Medical Center St Francis Designated District Hospital Philippine General Hospital Toronto General Hospital St Mary s Hospital Auckland City Hospital Amman Jordan 500 13 New Delhi India 733 15 Seattle Washington 410 24 Itakara Tanzania 3471 3 Manila Philippines 1800 39 Toronto Canada 744 149 London England 541 16 Auckland New Zealand 710 31 Public urban Charity urbar Public urban District rural Public urban Public urban Public urban Public urban St Mary s Hospital has since been renarned St Mary s Hospital lmperial College National Health Service Trust N ENGL ME
5. laxis of surgical infection the effect of prophylactic antimicrobial drugs on the incidence of infection following potential ly contaminated operations Surgery 1964 56 15 1 7 26 Hasselgren PO Ivareson L Risberg B Seeman T Effects of prophylactic antibi otics in vascular surgery a prospective randomized double blind study Ann Surg 1984 200 86 92 27 Barker PG LL Efficacy of prophylactic antibiotics for craniotomy a meta analy sis Neurosurgery 1994 35 464 92 28 Norden CW Antibiotic prophylaxis in orthopedic surgery Rev Infect Dis 1991 13 Suppl liksed2 se46 29 Mayo E The human problems of an industrial civilization New York Mac millan 1933 Cappicht 2000 Maesacliselts Medra Siacathy N ENGLIMED360O NEJM ORG JANUARY 29 2009 Downloaded from www nejm org on February 20 2009 For personal use only Ne other uses without permission Copyright 2009 Massachusetts Medical Society All rights reserved www albertahealthservices ca 495
6. provided additional oral confirmation of appro priate antibiotic use increasing the adherence rate from 56 to 83 this intervention alone has been shown to reduce the rate of surgical site infection by 33 to 388 Other potentially lifesaving measures Were also more likely to be instituted including an obiective airway evalua tion and use of pulse oximetry though the change in these measures was less dramatic Although the omission of individual steps was still fre quent overall adherence to the subgroup of six safety indicators increased by two thirds The sum of these individual systemic and behavioral changes could account for the improvements observed Another mechanism however could be the Hawthorne effect an improvement in perfor mance due to subjects knowledge of being ob served The contribution of the Hawthorne ef fect is difficult to disentangle in this study The checklist is orally performed by peers and is in tentionally designed to create a collective aware hess among surgical teams about whether safety processes are being completed However our analysis does show that the presence of study personnel in the operating room was not respon sible for the change in the rate of complications This study has several limitations The design involving a comparison of preintervention data N ENGL MED 3605 NEJM ORG Table 6 Selected Process Measures before and after Checklist Implementation According to Site
7. Each of the websites listed below have educational and supportive material including demonstration videos that can assist sites in understanding how to adopt and use the checklist appropriately htto www who int patientsafety safesurgery en http www ihi org IHI Programs ImprovementMap WHOSurgicalSafetyChecklist htm http www patientsafetyinstitute ca English toolsResources sssl Pages default aspx 4 3 Quality Improvement Strategies for Implementation AHS surgical teams sites should use a quality improvement approach to pilot the checklist and test the impact on current operational processes before full implementation The use of quality improvement techniques such as PDSA cycles to test suggested changes to existing OR processes are very useful before surgical groups fully implementing the checklist They enable teams to determine the impact the change has on efficiency and flow of procedures and ensure the quality of care and patient safety is maintained Clinical Quality Support staff are available to provide support to any site or surgical group regarding methods for piloting improvement initiatives such as the surgical checklist 4 4 Communication Strategies The development of a communication strategy by sites is critical to the success of any implementation and change management process Sites must develop methods to effectively promote the surgical checklist to all the key stakeholders patients surgeons anesthesiologist OR Sta
8. Supplementary Appendix 492 W ENGL MED 3605 NEJM ORG JANUARY 274 7005 Downloaded from www nejm org on February 20 2009 For personal use only No other uses without permission Copyright 2009 Massachusetts Medical Society All rights reserved www albertahealthservices ca AHS Safe Surgery Checklist Manual 30 ae Alberta Health Mm Services A SURGICAL SAFETY CHECKLIST these guidelines we designed a 19 item check list intended to be globally applicable and to reduce the rate of major surgical complications Table 1 For the formatted checklist see the Supplementary Appendix available with the full text of this article at NE M org We hypothesized that implementation of this checklist and the associated culture changes it signified would re duce the rates of death and major complications after surgery in diverse settings METHODS STUDY DESIGN We conducted a prospective study of preinterven tion and postintervention periods at the eight hospitals participating as pilot sites in the Safe Surgery Saves Lives program Table 2 These in stitutions were selected on the basis of their geo graphic distribution within WHO regions with the goal of representing a diverse set of socioeco nomic environments in which surgery is performed Table 3 lists surgical safety policies in place at each institution before the study We required that a coinvestigator at each site lead the project locally and that the hospit
9. WHO of 6 775 operations the implementation of a simple checklist completed during surgical procedures reduced the overall incidents of complications and death significantly Haynes AB et al A Surgical Safety Checklist to Reduce Morbidity and Mortality in a Global Population N Engl J Med 2009 360 491 9 see Appendix IV Alberta Health Services AHS is committed to improving patient safety and the quality of care for all Albertans Quality and safety have been identified within the AHS Strategic Direction 2009 2012 document as one of the 20 key strategic priorities for the organization The AHS Safe Surgery Checklist see Appendix I is being introduced as part of this commitment in Alberta to assist surgical teams in reducing the number of preventable surgical complications and further improve surgical results The AHS Safe Surgery Checklist while not limited to use in an operating room setting should apply to every patient undergoing a surgical procedure as defined below For the purpose of this manual the following definitions apply Surgical Procedure Any procedure involving an incision excision manipulation or suturing of tissue Any invasive or non invasive procedure that requires regional general or monitored anesthesia by an anesthesiologist or anesthetist which may be performed in or outside of an operating room setting Surgical Team Comprises the surgeons anesthesiologists nurses technicians and other pe
10. following provisions 1 Surgical checklists used by AHS sites must comply with the first eight objectives of the WHO Ten Essential Objectives for Safe Surgery 2 Surgical checklists used by AHS sites must encourage involvement by all members of the interdisciplinary surgical team in the communication of safety checks at three critical points o Before the induction of anesthesia Briefing o Before skin incision Time Out o Before the patient leaves the OR Debriefing 3 Modification or development of a surgical checklist s must involve surgeons anesthesiologists and nurses and must be trialed in simulated and real life situations to ensure functionality 4 AHS sites may develop more than one surgical checklist to suit the specific safety issues related to an individual surgical procedure or set of procedures Each individual checklist must comply with AHS see Section 2 0 and WHO see Section 1 1 guidelines 5 AHS sites that have modified the AHS Checklist or have developed their own checklist s are requested to supply a copy of the checklist s to the provincial zone leads Operational and or Clinical Quality Support Consultant or chairs of the Implementation Working Group for review see Appendix IV for list of Implementation Working Group members The members of the Implementation Working Group are available to support AHS sites with suggestions on modification implementation communication and quality improvement The except
11. listed in the Appendix This article 10 1056 NEJMsa0810119 was published at NEJM org on January 14 200 N Engl Med 2009 360 491 9 Copyright AME Manachari Medical Society 491 Downloaded fram werw nejm org on February 20 2009 For personal use only No other uses without permission Copyright 2 2009 Massachusetts Medical Society All rights reserved www albertahealthservices ca AHS Safe Surgery Checklist Manual 29 E Alberta Health W Services The NEW ENGLAND JOURNAL of MEDICINE URGICAL CARE IS AN INTEGRAL PART OF health care throughout the world with an estimated 234 million operations performed annually This yearly volume now exceeds that of childbirth Surgery is performed in every com munity wealthy and poor rural and urban and in all regions The World Bank reported that in 2002 an estimated 164 million disability adjusted life years representing 11 of the entire disease bur den were attributable to surgically treatable con ditions Although surgical care can prevent loss of life or limb it is also associated with a consid erable risk of complications and death The risk of complications is poorly characterized in many parts of the world but studies in industrialized countries have shown a perioperative rate of death from inpatient surgery of 0 4 to 0 8 and a rate of major complications of 3 to 17 These Table 1 Elements of the Surgical Safety Checklist rates are li
12. s review should involve the following e Are there any issues relating to sterility e Are there any issues relating to equipment The scrub nurse or technologist who sets out the equipment for the case should verbally confirm that sterilization was performed and that for heat sterilized instruments a sterility indicator has verified successful sterilization Any discrepancy between the expected and the actual sterility indicator results should be reported to all team members and addressed before incision This is also an opportunity to discuss any problems with equipment and other preparations for surgery During routine procedures or those with which the entire team is familiar the surgeon can simply state This is a routine case of X duration and then ask the anesthesiologist and nurse if they have any special concerns For many procedures that do not generally entail particularly critical risks or concerns anesthesiologist and nurse can also simply say I have no special concern regarding this case 12 Applicable Medication Concerns e Antibiotic Prophylaxis Given Within Last 60 Minutes This is another of the 10 WHO essential objectives for safe surgery Despite strong evidence and wide consensus that antibiotic prophylaxis against wound infections is most effective if serum and or tissue levels of antibiotic are achieved surgical teams are inconsistent about administering antibiotics within one hour prior to incision To reduce
13. surgical infection risk the individual leading the checklist will ask out loud whether prophylactic antibiotics were given during the previous 60 minutes The team member responsible for administering antibiotics typically the anesthesiologist should verbally confirm if prophylactic antibiotics have been administered and if not it should be administered prior to incision If prophylactic antibiotics have been administered longer than 60 minutes prior the team should consider re dosing the patient A simple verbal not applicable announcement will suffice if prophylactic antibiotics are not considered appropriate 7 i www albertahealthservices ca AHS Safe Surgery Checklist Manual 23 Alberta Health Mm Services e Thromboprophylaxis VTE Ordered VTE is one of the most common and preventable complications of hospitalization If VTE thromboprophylaxis is not instituted then 10 to 40 of general surgery patients and 40 to 60 of hip surgery patients will develop VTE This is not one of the WHO 10 essential objectives for safe surgery but is listed as a recommended addition that a number of countries have included in their checklist The medical members of the Surgical Checklist Steering Committee felt strongly that this must be part of the AHS Safe Surgery Checklist is not optional How to Guide Prevention of Venous Thromboembolism Safer Healthcare Now Campaign May 2008 http www saferhealthcarenow ca EN Interventions vt
14. to the patient or procedure 8 Each individual section of the checklist should not take more than 1 minute to complete unless issues have been identified which require action Ideally the checklist should add no more than 2 minutes of time in total to the surgical procedure 9 Briefing Section should occur prior to induction of anesthesia either in the holding area operating theatre or procedure room 10 Time Out Section should occur after induction and just prior to commencement of procedure before skin incision 11 Debriefing Section can occur simultaneously with wound closure but must occur prior to the surgeon leaving the room 2 2 Impact of the Safe Surgery Checklist for High Volume Cases Some AHS sites that participated in the provincial pilot of the surgical checklist identified some issues with the flow of cases particularly when using the surgical checklist with high volume cases Other sites did not experience any issues or negative impact on individual cases when implementing and integrating the checklist with any surgical procedure or group and found the checklist could be easily adapted to all groups AHS encourages sites to review the implementation strategy with the understanding that the surgical checklist should not negatively impact operational efficiency or impede the flow of surgical cases and procedures AHS sites are encouraged to consult with the resources identified to support implementation if any site or su
15. 12 4 0 Implementation of the AHS Safe Surgery Checklist ccccccccceceeeeeeeseeeeeeeseeeeeeeeeas 13 4 1 Recommended Process for Implementing the AHS Safe Surgery Checklist 13 4 2 Support for Implementing the AHS Safe Surgery Checklist cceceeeeeeeeeees 14 4 3 Quality Improvement Strategies for Implementation cccccccecsseeeeseeeeeeeesaeees 15 4 4 COMMUNICATION StrateGieS cccecccscscccessseececseeeceeceeeeeeceeeseeeeaeeeeeeseeeeeeesaeeeeeesaaes 15 4 5 Key Communication Messages to Assist with Implementation and Engagement 16 4 6 Physician Engagement Strategie cccccccccccessscceseeseeeesseeeeeesseeeeeeseaeeeeseeeeeeseas 16 Bf WICASUN SIS N c cease hasten EE EE R EE 17 7 al al B PG erent ene enn ee eee eee eee eee eee 18 AHS Sadie SWE CNECKIS eee eee ee ee eee eee 18 PP ND Iien E E E aaensinenideeuscanimeranodtanceues 19 Guidelines for Use of the AHS Safe Surgery Checklist detailed 00 000nn00nn00000n0n 19 APRENDI nee erence eee nen ee eee nee en eee eee ee 25 AHS Implementation Working Group Membership List ccccceeeeeeeeseeeeeeeeeeeeaees 25 APPENDIX cein ca vans anap dare sd ancnancgaaeatntdesan nee E E 28 PIG lete MGS PUIG IC eee sass banca iene E E ERE E EE E 28 www albertahealthservices ca AHS Safe Surgery Checklist Manual 4 Alberta Health Mm Services 1 Introduction According to a study by the World Health Organization
16. 254 Educator OR Foothills Medical Centre Deb Cartwright Lethbridge Alberta Deborah Cartwright albertahealthservices ca Director Clinical ph 403 388 6175 Quality Support south Zone Linda Tessmann Medicine Hat Alberta Linda Tessmann Potvin Potvin albertahealthservices ca Operational Lead ph 403 529 8931 MHRH Zone 2 Calga Zone2 Calgary O Karen Ruggles Calgary Alberta Karen Rugqgles albertahealthservice ca Quality Consultant ph 403 943 1643 Calgary Zone Darcee Clayton Calgary Alberta Darcee Clayton albertahealthservices ca Manager ph 403 944 4926 Foothills Medical Centre OR Zone 3 Central Zone 3 Central _ Z gt S OO Andrea Reber Camrose Alberta Andrea Reber albertahealthservices ca Quality Consultant oe 780 608 8598 East Central Janet Wolbeck Daysland Alberta Janet Wolbeck albertahealthservices ca Surgical Program e 780 781 1760 Lead Central Zone Rural Zone 4 Edmonton Beth Good Edmonton Alberta Beth Good albertahealthservices ca Quality Consultant ph 780 735 5261 Royal Alexandra Hospital Sandra Mageau St Albert Alberta Sandra Mageau albertahealthservices ca Patient Care Manager Ph 780 418 7312 Sturgeon Hospital Page 1 www albertahealthservices ca AHS Safe Surgery Checklist Manual 27 Alberta Health Mm Services 8 Alberta Health W Services Zone 4 Edmonton continued Lorraine Willox Edmonton Alberta Lorraine Willox albertahealthservi
17. D 360 NEJM ORG JANUARY 29 2004 Downloaded fom www nejm org on February 20 2009 For personal use only No other uses without permission Copyright 2009 Massachusetts Medical Society All rights reserved www albertahealthservices ca r Alberta Health Mm Services AHS Safe Surgery Checklist Manual 31 The NEW ENGLAND JOURNAL of MEDICINE DATA COLLECTION We obtained data on each operation from stan dardized data sheets completed by the local data collectors or the clinical teams involved in surgi cal care The data collectors received training and supervision from the primary investigators in the identification and classification of complications and process measures Perioperative data includ ed the demographic characteristics of patients procedural data type of anesthetic used and safe ty data Data collectors followed patients pro spectively until discharge or for 30 days which ever came first for death and complications Outcomes were identified through chart monitor ing and communication with clinical staff Com pleted data forms were stripped of direct identi fiers of patients and transmitted to the primary investigators We aimed to collect data on 500 consecutively enrolled patients at each site within a period of less than 3 months for each of the two phases of the study At the three sites at which this goal could not be achieved the period of data collection was extended for up to 3 additi
18. E Alberta Health W Services AHS Safe Surgery Checklist User Manual Version 2 0 January 20 2010 www albertahealthservices ca AHS Safe Surgery Checklist Manual 2 T Alberta Health W Services This manual was adapted from the WHO Guideline for Safe Surgery 2009 Edition which can be viewed with the Tools and Resources section of the WHO website Link Atto www who int patientsafety safesurgery en www albertahealthservices ca AHS Safe Surgery Checklist Manual 3 En Alberta Health Services Table of Contents Tane OF GOSS a E E E O E O tienes 3 e Arodu UON ee A T E E i 4 1 1 Ten Essential Objectives for Safe Surgery ccccceecececssseeeeeseeseeeeseneeeeseeeeeeseeaaeees 5 ARK Oy NOSS dO a E sondcuomernanareieas 6 1 3 Freguemntly Asked QUESO NG erroaren enn SN 7 2 0 Guidelines for Use of the AHS Safe Surgery Checklist 000n000nnnannnnennnnennnnenenennnnennnne 9 2 1 General Guidelines ccc ceeccccceeececeeeeeceeeceeseeeeceececeuueeeeenecesaueeetsueeesseeesseeetsnsees 9 2 2 Impact of the Safe Surgery Checklist for High Volume Cases ccceeeeeeeeeees 10 3 0 Modifying the Checklist cccccccccceeeececeeeeeceseeeeeeeseaeeceeeaeeeeeeeseeueeeeseaeeeessaaeeeeseeeeeenseas 11 3 1 Guidelines for Modification of AHS Safe Surgery Checklist cccccseeeeeeeeeeees 11 3 1 1 WHO Recommendation for Modifying the Surgical Checklist 0
19. a change in systems and individual behavior In this study a checklist based program was associated with a significant decline in the rate of complications and death from surgery in a diverse group of institutions around the world Applied on a global basis this checklist program has the potential to prevent large numbers of deaths and disabling compli cations although further study is needed to de termine the precise mechanism and durability of the effect in specific settings Supported by grants trom the World Health Organization No potential conflict of interest relevant to this article was reported APPENDIX The members of the Sate Surgery Saves Lives Study Group were as follows Amman Jordan AS Breizat AF Awamleh O G Sadieh Auckland New Zealand AF Merry 5 J Mitchell V Cochrane A M Wilkinson J Windsor N Robertson N Smith W Guthrie Y Beavis Makara Tanzania P Kibatala B Jullu R Mayoka M Kasuga W Sawaki N Pak London England A Darzi K Moorthy A vats R Davies K Nagpal M Sacks Manila Philippines T Herbosa M C M Lapitan G Herbosa C Meghrajani New Delhi India amp Joseph A Kumar H Singh Chauhan Seattle Washington E P Dellinger K Gerber Toronta Canada RE Reznick B Taylor A Slater Boston Massachusetts W R Berry A A Gawande A B Haynes 5 B Lipsitz T G Weiser Geneva Switzerland L Donaldson G Dziekan P Philip Baltimore Maryland M Makary Ankara
20. afe Surgery Checklist please refer to Appendix II AHS sites are advised to review the WHO Safe Surgery website for additional support in understanding how to use the checklist Alternatively the Institute for Healthcare Improvement IHI and the Canadian Patient Safety Institute CPSI also have educational and supportive material including demonstration videos that may be beneficial to AHS sites website addresses listed below htto www who int oatientsafety safesurgery en htto www ithi org IHI Programs ImprovementMap WHOSurgicalSafetyChecklist htm htto www patientsafetyinstitute ca English toolsResources sssl Pages default aspx 2 1 General Guidelines 1 The AHS Safe Surgery Checklist is intended as a communication tool that requires participation of ALL members of the surgical team 2 AHS strongly urges ALL members of surgical team be present for all three 3 portions of the checklist Briefing Time Out and Debriefing While it may not always be possible for all team members to be available to participate in the Briefing all members of the surgical team MUST be present for the Time Out and Debriefing portions Team members who are not able to attend the Briefing must pre arrange to discuss the details of Briefing section with the other members of the surgical team prior to the case 3 AHS urges AHS surgical teams to include when appropriate patients or family members for the Briefing portion of the checklist 4 Su
21. after checklist irmplernentation on the basis of P values calculated by means of the chi Square test or Fishers exact test P values are shown for the comparison of the total value after checklist implernentation as compared with the total value before irmplernentation 496 absence of a direct observer nor changes in case mix affected the significance of the changes in the rate of complications P lt 0 001 for both alter native models or the rate of death P 0 003 with the presence or absence of direct observation in cluded and P 0 002 with case mix variables included Rates of complication fell from 10 3 before the introduction of the checklist to 7 1 after its introduction among high income sites P lt 0 001 and from 11 7 to 6 8 among lower income sites P lt 0 001 The rate of death was re duced from 0 9 before checklist introduction to 0 6 afterward at high income sites P 0 18 and from 2 1 to 1 0 at lower income sites P 0 006 although only the latter difference was signifi cant In the cross validation analysis the effect of the checklist intervention on the rate of death or complications remained significant after the removal of any site from the model P lt 0 05 We also found no change in the significance of the effect on the basis of clustering P 0 003 for the rate of death and P 0 001 for the rate of com plications Table 6 shows the changes in six measured processes at each site after introduction of t
22. al administration support the intervention A local data collector was chosen at each site and trained by the four primary investi gators in the identification and reporting of pro cess measures and complications This person worked on the study full time and did not have clinical responsibilities at the study site Each hos pital identified between one and four operating rooms to serve as study rooms Patients who were 16 years of age or older and were undergoing non Table 2 Characteristics of Participating Hospitals cardiac surgery in those rooms were consecutively enrolled in the study The human subiects com mittees of the Harvard School of Public Health the WHO and each participating hospital ap proved the study and waived the requirement for written informed consent from patients INTERVENTION The intervention involved a two step checklist implementation program After collecting base line data each local investigator was given infor mation about areas of identified deficiencies and was then asked to implement the 19 item WHO safe surgery checklist Table 1 to improve prac tices within the institution The checklist consists of an oral confirmation by surgical teams of the completion of the basic steps for ensuring safe delivery of anesthesia prophylaxis against infec tion effective teamwork and other essential prac tices in surgery It is used at three critical junctures in care before anesthesia is administered
23. al information is shared with all members of the surgical team which is aligned to one of AHS key objectives for improving patient safety and quality of care It also helps focus the entire team on patient safety at three critical stages during the surgical procedure before induction before incision and before closing The checklist is simply a communication tool for members of a surgical team It does not replace existing procedures or safety checks but builds on them by ensuring the entire interdisciplinary team is involved in the safety communication at the same time Q We are already very busy in the OR Isn t this just one more task using up valuable time A In actuality it may save time Once the checklist becomes familiar to operating room teams it requires very little extra time to perform The AHS Safe Surgery Checklist is intended to only take no more than one 1 minute for each of the three stages to complete unless issues arise while adding no more than two 2 minutes in total to the surgical procedure time The checklist can save time by identifying potential issues before they arise ensuring better co ordination between team members and minimizing delays caused by retrieving additional equipment etc Q Is the surgical checklist another document and considered part of the patient record A No the surgical checklist is not meant to serve as a formal document and is not considered suitable for charting or recording It is
24. all portions relating to anesthesia The responsibility for the checklist lies with every member of the OR team including surgeons anesthesiologists nurses technicians and any other OR staff members Q What procedures do you use the AHS Safe Surgery Checklist for A AHS has defined surgery very broadly to include any procedure involving an incision excision manipulation or suturing of tissue requiring regional general or monitored anesthesia by an anesthesiologist or anesthetist The surgical checklist is not limited to only formal operating room settings and can be adapted to any procedure room at any AHS site to improve patient safety It is up to the sites to evaluate which procedures the checklist is suitable for The WHO recommends the surgical checklist be adapted in any environment and setting where surgical procedures are being completed including and not limited to emergency department procedure rooms birth centers performing c sections radiology departments performing invasive radiology procedures etc Q What is the target date for implementation A AHS is asking sites to introduce the AHS Safe Surgery Checklist to all surgical groups within existing functional operating room settings by April 2010 The use of a surgical checklist will become an Accreditation Canada requirement for all sites in Canada going through accreditation based on standards dated as of 2011 Q Is there support for surgical groups implementing
25. anded during the course of an operation the individual leading the checklist should confirm with the surgeon and the team exactly what procedure was done This can be done as a question What procedure was performed or as a confirmation We performed X procedure correct e Applicable Sponge and Instrument Counts Retained instruments sponges and needles are uncommon but persistent and potential errors that may result in serious harm to the patient The scrub or circulating nurse should therefore verbally confirm the completeness of final soonge and needle counts In cases with an open cavity instrument counts should also be confirmed to be complete If counts are not appropriately reconciled the team should be alerted so that appropriate steps can be taken such as examining the drapes garbage and wound or if need be obtaining radiographic images e Specimen Labeling and Handling Incorrect labeling of pathological specimens is potentially disastrous for a patient and has been shown to be a frequent source of errors The scrub or circulating nurse should confirm the correct labeling of any pathological soecimen obtained during the procedure by reading out loud the patient s name the specimen description and any orienting marks e Whether There Are Any Equipment Problems to be Addressed Equipment problems are universal in operating rooms Identifying the sources of instruments or equipment failure is important in preventing devices fro
26. care delivered to their patients by the introduction of the AHS Safe Surgery Checklist This manual has been created to assist sites 1 In understanding how to use the AHS Safe Surgery Checklist 2 With the implementation of the AHS Safe Surgery Checklist to all surgical services within a site 3 Who wish to modify the AHS Safe Surgery Checklist to further improve surgical results and decrease associated complications while still being compliant with AHS Safe Surgery Guidelines see Section 2 0 and the ten essential safety objectives established by the WHO 7 i www albertahealthservices ca AHS Safe Surgery Checklist Manual 6 En Alberta Health WE Services 1 2 Key Messages e The AHS Safe Surgery Checklist is meant as a communication tool to be used by AHS surgical teams to help ensure the safety of its patients it is not meant to be used as a formal document e AHS surgical teams can use paper electronic or poster versions of the AHS Safe Surgery Checklist e The AHS Safe Surgery Checklist does not replace any existing documentation or safety check procedures currently used at any AHS site e AHS sites must identify a surgical checklist which must be used by surgical teams in compliance with Accreditation Canada ROP standard e AHS has developed an AHS Safe Surgery Checklist see Appendix for general purpose use which can be used by AHS sites e AHS sites can modify or develop their own surgical checklist s with the
27. cations occurred in 11 0 of patients at paseline and in 7 0 after introduction of the checklist P lt 0 001 CONCLUSIONS Implementation of the checklist was associated with concomitant reductions in the rates of death and complications among patients at least 16 years of age who were undergoing noncardiac surgery in a diverse group of hospitals HENGLIMED 3605 NEJMLORG JANUARY 2G 2009 From the Harvard School of Public Health ABH T G W WRB AA GJ Massa chusetts General Hospital A B H j and Brigham and Women s Hospital R L AAG all in Boston University of California Davis Sacramento T W Prince Hamzah Hospital Ministry of Health Amman Jordan 4 H 5 B Uni versity of Washington Seattle E P 0 College of Medicine University of the Philippines Manila T H St Stephen s Hospital New Delhi India SJ St Fran cis Designated District Hospital Ifakara Tanzania PLK National Institute of Health University of the Philippines Manila M C M LJ University of Auck land and Auckland City Hospital Auck land New Zealand AFM Imperial College Healthcare National Health Ser vice Trust London KM and University Health Network University of Toronto Toronto R K R B T Address reprint re quests to Dr Gawande at the Depart ment of Surgery Brigham and Women s Hospital 75 Francis St Boston MA 07115 or at Safesurpery hs ph harvard edu Members of the Safe Surgery Saves Lives Study Group are
28. ced by modifying the anesthesia plan for example using rapid induction techniques and enlisting the help of an assistant to provide pressure during induction For a patient recognized as having a difficult airway or being at risk for aspiration induction of anesthesia should begin only when the anesthesiologist confirms that he or she has adequate equipment and assistance present at the bedside 6 Patient Positioning and Support Confirmed To prevent delays the surgeon must review their plan for patient positioning and support requirements for the team If the surgeon is unable to attend the Briefing portion of the checklist they must ensure that a review occurs with the attending anesthesiologist prior to the team briefing 7 Relevant Special Equipment Confirmed and In Room The individual leading the checklist should verbally review the need for any relevant and special equipment not normally found in the theatre This may include but is not limited to confirmation that prosthesis warming devices or loaner instruments are checked and confirmed This box is optional on the checklist and may be removed if not applicable to local procedures 8 Relevant Tests completed and checked The individual leading the checklist should verbally confirm that someone has reviewed and confirmed the completion and availability of all relevant laboratory and radiology procedures This may include confirmation of pregnancy test for female patients completion of a ty
29. ces ca Clinical Nurse ph 780 407 1802 Educator Level 1 Operative Services Stollery Children s Hospital one STN Lori Flynn Fort McMurray Lori Flynn albertahealthservices ca North Zone Rita Young Grande Prairie Rita Young albertahealthservices ca Unit Manger OR ph 780 538 7462 PACU QE11 Hospital John Cabral Grande Prairie John Cabral albertahealthservices ca Operational Lead Alberta ph 780 538 7296 Clinical and Therapeutics QE11 Hospital Covenant Health Trevor Small Edmonton Alberta Trevor Small covenanthealth ca Director of Surgery ph 780 735 7501 Grey Nuns Community Hospital Page 2 www albertahealthservices ca AHS Safe Surgery Checklist Manual 28 E Alberta Health W Services APPENDIX IV Reference Article Haynes AB et al A Surgical Safety Checklist to Reduce Morbidity and Mortality in a Global Population N Engl J Med 2009 360 491 9 Th NEW ENGLAND JOURNAL of MEDICINE SPECIAL ARTICLE A Surgical Safety Checklist to Reduce Morbidity and Mortality in a Global Population Alex B Haynes M D M P H Thomas G Weiser M D M P H William R Berry M D M P H Stuart R Lipsitz 5c D Abdel Hadi 5 Breizat M D Ph D E Patchen Dellinger M D Teodoro Herbosa M D Sudhir Joseph M 5 Pascience L Kibatala M D Marie Carmela M Lapitan M D Alan F Merry M B Ch B F A N Z C A FRCA Krishna Moorthy M D F R C S Richard K Reznick M E M Ed Bryce Ta
30. e Documents VTE 20Getting 20Started 20Kit pdf e Other Specific Medication Concerns This provides the team to highlight any additional medication related concerns 13 Essential Imaging Displayed Imaging is critical to ensure proper planning and conduct of many operations and is one reason for delays Before skin incision the individual leading the checklist should ask the surgeon if imaging is needed for the case and confirmation that essential imaging is available and prominently displayed If imaging is needed but not available it should be obtained and the surgeon can decide whether to proceed without the imaging 14 Any Other Questions or Concerns Before Proceeding This provides all members of the team the opportunity to voice any concerns prior to commencement www albertahealthservices ca AHS Safe Surgery Checklist Manual 24 En Alberta Health WE Services ill Before Patient Leaves Operating Room DEBRIEFING These safety checks should be completed before removing the patient from the operating room The aim is to facilitate the transfer of important information to the care teams responsible for the patient after surgery The checks can be initiated by the circulating nurse surgeon or anesthesiologist and should be accomplished before the surgeon has left the room It can coincide with wound closure 15 Surgical Team Have Verbally Confirmed e The Name of the Procedure Since the procedure may have changed or exp
31. e goal of the AHS Safe Surgery Checklist is to help ensure that teams consistently follow a few critical safety steps and thereby minimize the most common and avoidable risks that endanger the lives and well being of surgical patients 4 1 Recommended Process for Implementing the AHS Safe Surgery Checklist 1 Identify Champions e Identify a surgical anesthesia and nursing lead at each site to develop a strategic planned approach for implementing the surgical checklist 2 Meet with Hospital Site Leaders e Ensure support for implementation and discuss how the hospital site leadership can assist in promoting the checklist 3 Start to Communicate the Message e Develop a communication strategy e Start the communication by introducing the surgical checklist to all members of the Surgical team surgeons anesthesiologist nursing and other OR staff members o Recommend presentation of the surgical checklist by the surgical lead at site regional surgical meetings 4 Identify a Surgical Group e Identify and approach a surgical group most likely to be supportive of the surgical checklist and would be willing to be the first to use the checklist 5 Involve Site Clinical Quality Support Consultants e Clinical Quality Support staff can provide surgical groups with guidance in strategic approaches for implementation measurement of quality improvement piloting strategies etc 6 Builda Team e Establish a site or service project team with represen
32. e hospitals was chosen because it was not possible to ran domly assign the use of the checklist to specific Operating rooms without significant cross con tamination One danger of this design is con founding by secular trends We therefore confined the duration of the study to less than 1 year since a change in outcomes of the observed magnitude is unlikely to occur in such a short period as a result of secular trends alone In addition an evaluation of the American College of Surgeons National Surgical Quality Improvement Program cohort in the United States during 2007 did not reveal a substantial change in the rate of death and complications Ashley personal commu nication http acsnsgip org We also found no change in our study groups with regard to the rates of urgent cases outpatient surgery or use of general anesthetic and we found that chang es in the case mix had no effect on the signifi cance of the outcomes Other temporal effects such as seasonal variation and the timing of surgical training periods were mitigated since the study sites are geographically mixed and have different cycles of surgical training There fore it is unlikely that a temporal trend was re sponsible for the difference we observed between the two groups in this study Another limitation of the study is that data collection was restricted to inpatient complica tions The effect of the intervention on outpatient complications is not
33. ecklist with team members sitting around a table Suggest using the Checklist for a single day by a single operating team and collecting feedback to ensure an easy fit in the flow for the operating room e Plan the wider implementation to all groups Integrated e Many of the processes that are part of the WHO Checklist are part of the current processes for ensuring safe surgical outcomes The major additions to existing routines involve the integration of team communication briefings and debriefings which are of critical importance and should not be removed from the Checklist Teams may consider adding other safety checks for specific procedures particularly if they are part of a routine process established in the facility o availability of essential implants such as mesh or a prosthetic specific equipment needs o critical preoperative biopsy results www albertahealthservices ca AHS Safe Surgery Checklist Manual 13 En Alberta Health WE Services 4 0 Implementation of the AHS Safe Surgery Checklist The following section provides suggestions and recommendations for implementing the checklist with different surgical groups at AHS sites understanding that different practice settings will adapt the use and performance of the surgical checklist to their own circumstance AHS recommends that each surgical team practice with the checklist to ensure the integration can easily be adapted into everyday practice The ultimat
34. ed surgical audit with the POSSUM scoring system in a developing country Br Surg 200289 110 3 8 McConkey SJ Case series of acute ab dominal surgery in rural Sierra Leone World J Surg 2002 26 599 15 Guro Bang na Maman AF Tomta K Ahouangbevi Chobli M Deaths associ ated with anaesthesia in Togo West Afri ca Trop Doct 2005 35 220 2 10 Dellinger EP Hausmann M Bratzler DW et al Hospitals collaborate to de crease surgical site infections Am J Surg 20005 190 9 15 ll Classen DC Evans RS Pestotnik SL Horr SD Menlove RL Burke JP The tim ing of prophylactic administration of an tibiotics and the risk of surzical wound infection N Engl Med 1992 326 261 6 A SURGICAL SAFETY CHECKLIST 12 Runciman WB Iatrogenic harm and anaesthesia in Australia Anaesth Inter sive Care 2005 35 297 300 13 Mazzocco K Petitti DB Fong KT etal Surgical team behaviors and patient out comes Am Surg 2008 Septernber 11 Epub ahead of print 14 Lingard L Regehr G Orser B et al Evaluation of a preoperative checklist and tam briefing among surgeons nurses and anesthesiologists to reduce failures in communication Arch Surg 2006 143 12 8 15 World Alliance for Patience Safety WHO guidelines tor sate surgery Geneva World Health Organization 2008 16 World Bank Data amp statistics country dassification Accessed January 5 2000 at hepsiro wvorldbank orgK 2CRMFGCC 17 Khon F Daley J Hender
35. esence nor Table 4 Characteristics of the Patients and Procedures before and after Checklist Implementation According to Site No of Site No Patients Enrolled Before After Age Before After pears Outpatient Procedure Before After Female Sex Before After Urgent Case After percent Before 524 357 497 520 370 496 525 444 Total 3733 P value 598 331 486 a ey 330 4 6 585 28 3955 51 9415 3 3 5418 4 51 94215 Yr 014 9 34 3 15 0 44 6415 9 37 4214 0 41 9415 8 46 82 18 1 51 4 14 7 54 0 18 3 53 0420 3 56 14 15 0 31 5 14 2 46 0415 5 39 6414 9 39 16 2 46 7 17 9 58 2 a4 44 3 44 1 a4 45 0 69 1 97 0 50 7 62 7 oo 49 8 49 6 18 4 46 6 68 6 a2 f 57 6 7A 1 amp 17 9 6 9 46 1 284 45 7 dow 223 0 14 5 224 1 8 65 4 22 0 41 0 219 23 3 31 7 23 5 6 4 14 4 0 0 Lit 0 0 0 9 9 9 31 8 20 5 2 3 11 0 0 0 1 1 0 0 0 2 94 General Anesthetic Before After 95 0 ff 91 2 96 9 17 0 Gl 49 1 97 3 ATO 95 2 93 5 94 0 ELE 10 0 29 9 55 9 94 773 0 68 Plus minus values are means 5D Urgent cases were those in which surgery within 24 hours was deerned necessary by the clinical tearn Outpatient procedures were those for which discharge from the hospital occurred on the same day as the operation P values are shown for the cornparison of the total value after checklist irmplernentation with the total value before irm
36. ess and fluids are available Time out Before skin incision the entire tear nurses surgeons anesthesia professionals and any others participating in the care of the patient orally Confirms that all tearn rembers have been introduced by name and role Confirms the patient s identity surgical site and procedure Reviews the anticipated critical events Surgeon reviews critical and unexpected steps operative duration and anticipated blood loss Anesthesia staf review concerns specific to the patient Nursing staff review confirmation of sterility equiprnent availability and other concerns Confirms that prophylactic antibiotics have been administered s60 min before incision is made or that antibiotics are not indicated Confirms that all essential imaging results for the correct patient are displayed in the operating roorn Sign out Before the patient leaves the operating room Nurse reviews iteris aloud with the tearn Name of the procedure as recorded That the needle sponge and instrument counts are complete or not applicable That the specimen if any is correctly labeled including with the patient s name Whether there are any issues with equipment to be addressed The surgeon nurse and anesthesia professional review aloud the key concerns for the recovery and care of the patient The checklist is based on the first edition of the WHO Guidelines for Safe Surgery For the complete checklist see the
37. ety check which may involve formal inspection of all anesthetic equipment breathing circuit medications and review of the patient s anesthetic risk The anesthesia team should complete the ABCDE s Airway equipment Breathing system including oxygen and inhalational agents suction drugs and devices and emergency medications equipment 7 i www albertahealthservices ca AHS Safe Surgery Checklist Manual 20 Alberta Health Mm Services 5 Difficult Airway Aspiration Risk The individual leading the checklist should verbally confirm that the anesthesia team has objectively assessed whether the patient has a difficult airway Death from airway loss during anesthesia is still a common disaster globally but is preventable with appropriate planning If the airway evaluation indicates a high risk for a difficult airway the anesthesia team must prepare against any potential issues including but not limited to adjusting the approach to anesthesia for example using a regional anesthetic if possible and having emergency equipment accessible A capable assistant whether a second anesthesiologist the surgeon or a nursing team member should be physically present to help with induction of anesthesia The risk of aspiration should also be evaluated as part of the airway assessment If the patient has symptomatic active reflux or a full stomach the anesthesiologist must prepare for the possibility of aspiration The risk can be redu
38. ff hospital staff hospital leadership etc The Implementation Working Group see Appendix III has tools and support that can be made available to sites upon request that may assist in effectively communication and message to all The communication strategy should be included as part of the implementation plan for each site e Templates for posters that can be used by sites to promote the use of the surgical checklist can be obtained from the Operational Working Group see Appendix III and an example will be included as part Implementation Package e Communication strategies and material can be found at websites listed below o http Awww who int patientsafety safesurgery en o http www ihi org IHI Programs ImprovementMap WHOSurgicalSafetyChecklist htm o http Awww patientsafetyinstitute ca English toolsResources sss l Pages default aspx 7 i www albertahealthservices ca AHS Safe Surgery Checklist Manual 16 En Alberta Health WE Services Additional support will be provided to sites through the Implementation Working Group see Appendix II which can share communication tools and power point presentations that were used by other sites around the province to promote the surgical checklist Communication strategies used by AHS pilot sites included e Posters in the operating rooms e Presentation by surgical anesthesiology site leads at medical rounds e Presentation at site based quality and safety committees e Presenta
39. five 5 provincial zones see Appendix Ill Each Zone will have an operational representative and a Clinical Quality Support CQS Consultant representative These individuals will provide direct support and guidance for sites The Zone operational and CQS representatives are members of the provincial Working Group which act as the communication link for sites to the Provincial Steering Committee and report on the progress of the implementation The working group will have available to them the knowledge that was developed at AHS during the pilot phase and involve individuals that have supported and assisted in the development of the AHS Safe Surgery Checklist and this manual CPSI and Safer Healthcare Now SHN have announced Checklist Action Series and workshops to support Canadian sites with the implementation of the surgical checklist AHS supports and 7 i www albertahealthservices ca AHS Safe Surgery Checklist Manual 15 r Alberta Health WE Services recommends sites take advantage of the opportunity to participate link for information and registration details can be found on the CPSI website htto www patientsafetyinstitute ca English toolsResources sssl Pages default aspx AHS sites are advised to review the WHO Safe Surgery the Institute for Healthcare Improvement IHI and the Canadian Patient Safety Institutes CPSI website for support in understanding how to implement the checklist as part of their routine
40. he checklist During the baseline period all six mea sured safety indicators were performed for 34 2 of the patients with an increase to 56 7 of patients after implementation of the checklist N ENGL J MED 4605 NEJM ORG P lt 0 001 At each site implementation of the checklist also required routine performance of team introductions briefings and debriefings but adherence rates could not be measured DISCUSSION Introduction of the WHO Surgical Safety Check list into operating rooms in eight diverse hospi tals was associated with marked improvements in surgical outcomes Postoperative complication rates fell by 36 on average and death rates fell by a similar amount All sites had a reduction in the rate of maior postoperative complications with a significant reduction at three sites one in a high income location and two in lower income locations The reduction in complications was maintained when the analysis was adjusted for case mix variables In addition although the ef fect of the intervention was stronger at some sites than at others no single site was responsible for the overall effect nor was the effect confined to high income or low income sites exclusively The reduction in the rates of death and complications suggests that the checklist program can improve the safety of surgical patients in diverse clinical and economic environments Whereas the evidence of improvement in sur gical outcomes is substantia
41. he impact on current processes before fully implementing the checklist fi Test Drive the Checklist e Trial the checklist in one operating room with one team then move forward after problems have been addressed o Some provincial sites involved in the original pilot phase found it useful to Seta targeted go live date Roll out introduce the checklist to different surgical groups for a week of practice runs Practice with a new surgical group each week Address comments or concerns at the project team level o As you spread the implementation of the checklist use the learning from previous teams to assist new teams with implementation fii Implement After a Practice Run 9 Monitor Implementation Progress e The Implementation Working Group will Support sites surgical groups in monitoring the progress of the implementation 10 Measure Usage and Impact on Outcome e Measurement of the usage and outcome of implementation will be developed by the AHS Safe Surgery Checklist Steering Committee and will be communicated to sites when available 11 Communicate the Progress of the Implementation to All Surgical Members 12 Celebrate and Reward Successes EGG 4 2 Support for Implementing the AHS Safe Surgery Checklist AHS will be supporting AHS sites with implementation of the AHS Safe Surgery Checklist An Implementation Working Group has been established to provide direct support for sites in each of the
42. he surgical checklist must be viewed by physicians as adding value to patient care and improving the outcome for their surgical patients The key to the success of the implementation lies with ensuring that physicians at each site take ownership are consulted and are involved with all aspects of the review and implementation process Their involvement and participation on site based implementation teams is essential Some physicians may view the checklist as a nursing tool and project team should ensure surgeons and anesthesiologists understand that it is a surgical safety tool that requires the involvement and active participation of all members of the surgical team 7 i www albertahealthservices ca AHS Safe Surgery Checklist Manual 17 Alberta Health Mm Services Names of physician that are willing to act as mentors to other physicians are available through the Implementation Working Group see Appendix Ill These are surgeons and anesthesiologists that were involved in the piloting of the checklist and the design of AHS Safe Surgery Checklist that are willing to discuss the checklist and their experience using the checklist with other physicians 4 7 Measurement AHS has established a Measurement Working Group to develop a provincial measurement plan which will provide long term review and reporting in compliance with the new Accreditation Canada Surgical Checklist ROP standard The AHS Safe Surgery Checklist provincial steering co
43. ion are for sites that have only made minor modifications to the AHS Safe Surgery Checklist specifically the addition or removal of non bold bullet points that this manual has identified as optional See Section 3 1 Guidelines for Modification of AHS Checklist 7 i www albertahealthservices ca AHS Safe Surgery Checklist Manual 7 En Alberta Health WE Services 1 3 Frequently Asked Questions Q Where did the idea of a safe surgery checklist come from A The original concept of the safe surgery checklist stems from the World Health Organization s WHO 2007 08 Safe Surgery Saves Lives campaign which built on the experience of medical experts healthcare professions safety experts and patients from around the world The Canadian Patient Safety Institute CPSI and the Royal College of Physicians and Surgeons of Canada RCPSC in collaboration with 15 in country organizations led the Canadian adaptation of the WHO campaign A provincial AHS committee was established in early 2009 to develop and implement a provincial plan for adopting the checklist within all AHS facilities Safety checks in operating room settings are not novel and the concept of the checklist was built on systems used internationally to help ensure safety of surgical patients Q Why should we use a surgical checklist A The surgical checklist has been shown to reduce the number of preventable complications associated with surgery by ensuring critic
44. kely to be much higher in developing countries Thus surgical care and its attendant complications represent a substantial burden of disease worthy of attention from the public health community worldwide Data suggest that at least half of all surgical complications are avoidable Previous efforts to implement practices designed to reduce surgical site infections or anesthesia related mishaps have been shown to reduce complications significant lyse A growing body of evidence also links teamwork in surgery to improved outcomes with high functioning teams achieving significantly reduced rates of adverse events 11 In 2008 the World Health Organization WHO published guidelines identifying multiple recommended practices to ensure the safety of surgical patients worldwide On the basis of Sign in Before induction of anesthesia members of the tear at least the nurse and an anesthesia professional orally confirm that The patient has verified his or her identity the surgical site and procedure and consent The surgical site is rnarked or site rnarking is not applicable The pulse oxirneter is on the patient and functioning All mernbers of the tearn are aware of whether the patient has a known allergy The patient s airway and risk of aspiration have been evaluated and appropriate equipment and assistance are available If there is a risk of blood loss of at least 500 ml or 7 ml kg of body weight in children appropriate acc
45. known This limitation is particularly relevant to patients undergoing out patient procedures for whom the collection of outcome data ceased on their discharge from the hospital on the day of the procedure resulting in an underestimation of the rates of complica tions In addition data collectors were trained in the identitication of complications and collection of complications data at the beginning of the study There may have been a learning curve in the pracess of collecting the data However if this were the case it is likely that increasing num bers of complications would be identified as the study progressed which would bias the results in the direction of an underestimation of the effect One additional concern is how feasible the checklist intervention might be for other hospi tals Implementation proved neither costly nor lengthy All sites were able to introduce the checklist over a period of 1 week to 1 month Only two of the safety measures in the checklist entail the commitment of significant resources use of pulse oximetry and use of prophylactic antibiotics Both were available at all the sites including the low income sites before the inter vention although their use was inconsistent Surgical complications are a considerable cause of death and disability around the world They are devastating to patients costly to health care systems and often preventable though their pre vention typically requires
46. l and robust the ex JANUARY 29 2009 Downloaded from www nejm org on February 20 2009 For personal use only No other uses without permission Copyright 2009 Massachusetts Medical Society All rights reserved www albertahealthservices ca AHS Safe Surgery Checklist Manual 34 ae Alberta Health Mm Services A SURGICAL SAFETY CHECKLIST act mechanism of improvement is less clear and most likely multifactorial Use of the checklist involved both changes in systems and changes in the behavior of individual surgical teams To implement the checklist all sites had to introduce a formal pause in care during surgery for preop erative team introductions and briefings and postoperative debriefings team practices that have previously been shown to be associated with improved safety processes and attitudes and with a rate of complications and death reduced by as much as 80 The philosophy of ensur ing the correct identity of the patient and site through preoperative site marking oral confirma tion in the operating room and other measures proved to be new to most of the study hospitals In addition institution of the checklist re quired changes in systems at three institutions in order to change the location of administration of antibiotics Checklist implementation encour aged the administration of antibiotics in the op erating room rather than in the preoperative wards where delays are frequent The checklist
47. l equipment confirmed and in room heading Relevant tests completed and checked heading Laboratory bullet point Radiology bullet point Pregnancy bullet point Crossmatch Type and Screen bullet Note Sites are NOT permitted to remove Risk of Blood Loss bullet point in the Time Out section Optional Time Out Checklist Items h Procedure duration bullet point i Thromboprophylaxis VTE ordered bullet point for pediatric procedures ONLY j Anticoagulant bullet point k Mechanical bullet point 3 Sites are free to modify the following aspects of the checklist a Color b Formatting c Language terminology d Move individual checklist items to another section of the checklist i e move Essential imaging displayed to Briefing Section etc to correspond to current surgical routines e Duplicate essential items in multiple sections f Add designation of Surgical lead g Separate and color code the checklist according to Surgical lead 4 The process of modification at a site must involve members of the surgical team Surgeons anesthesiologists nurses and other members of the surgical team and the resulting checklist trialed in simulated and real life situations in order to ensure its functionality 7 i www albertahealthservices ca CE AHS Safe Surgery Checklist Manual 12 En Alberta Health Mm Services 3 1 1 WHO Recommendation for Modifying the Surgical Checklist The WHO has
48. lan Patient disposition Analgesia Da needs for transfer Specific concerns This chechist wee adapted from ihe reord Aeallh Organization MAO Surgical Safely Chechist URL iif wwe ww ho ntepa ien saap saie sugen en E brood Heath Organization 2006 Ail Rights Reserved Version 8 Jan 27 2005 www albertahealthservices ca AHS Safe Surgery Checklist Manual 19 Alberta Health Mm Services APPENDIX Il Guidelines for Use of the AHS Safe Surgery Checklist detailed l Before Induction of Anesthesia BRIEFING These safety checks are to be completed before induction of anesthesia in order to confirm that key safety procedures have been completed and reviewed before proceeding AHS strongly urges that all members of the surgical team make every effort to attend and participate at each of the three portions of the surgical checklist The individual leading the checklist may complete this section all at once or sequentially depending on the flow of preparation for anesthesia The details for each of the safety steps are as follows 1 Patient family member and or Surgical Team Members have Verbally Confirmed The individual leading the checklist for this section verbally confirms e patient s identity e procedure e site side or level e consent for surgery has been given While it may seem repetitive this step is essential for ensuring that the team does not operate on the wrong patient wrong site or perf
49. llector in the operating room and the case mix were added as variables We classified cases as orthopedic thoracic nonobstet ric abdominopelvic obstetric vascular endoscop ic or other To determine whether the effect of the checklist at any one site dominated the re sults we performed cross validation by sequen tially removing each site from the analysis Final ly we disaggregated the sites on the basis of whether they were located in high income or low or middle income countries and repeated our analysis of primary end points All reported P values are two sided and no adiustments were made for multiple comparisons RESULTS We enrolled 3733 patients during the baseline period and 3955 patients after implementation of the checklist Table 4 lists characteristics of the patients and their distribution among the sites there were no significant differences between the patients in the two phases of the study The rate of any complication at all sites dropped from 11 0 at baseline to 7 0 after introduction of the checklist P lt 0 001 the total in hospital rate of death dropped from 1 5 to 0 8 P 0 003 Table 5 The overall rates of surgical site infection and unplanned reoperation also declined significantly P lt 0 001 and P 0 047 respectively Operative data were collected by the local data collector through direct observation for 37 5 of patients and by unobserved clinical teams for the remainder Neither the pr
50. m being recycled back into the room The individual leading the checklist should ensure that equipment problems arising during a case are identified by the team 16 Surgical Team Has Reviewed the Recovery Plan The surgeon anesthesiologist and nurse should review the post operative recovery and management plan focusing in particular on intraoperative or anesthetic issues that might affect the patient Events that present a specific risk to the patient during recovery may not always be evident to all members of the surgical and recovery team The aim of this step is the efficient and appropriate transfer of critical information to the entire team so the following issues should be reviewed Patient Disposition Analgesia O2 Needs for Transfer Specific Concerns With this final step the AHS Checklist is completed 7 i www albertahealthservices ca AHS Safe Surgery Checklist Manual 25 T Alberta Health W Services APPENDIX III AHS Implementation Working Group Membership List www albertahealthservices ca AHS Safe Surgery Checklist Manual 26 En Alberta Health WE Services E Alberta Health Services Implementation Working Group Membership List Member _______ Location Contact Information Debra Scharff Edmonton Alberta Debra Scharff albertahealthservices ca Patient Safety Division os 480 735 058 1 Lucia Pfeuti Calgary Alberta Lucia Pfeuti albertahealthservices ca Clinical Nurse JL Sc cn 403 944 1
51. mmitiee will ensure the measurement plan is relevant to sites using either paper OR charting or electronic patient management systems The plan will include identification of appropriate metrics for both usage and outcome and ensure reporting to key local zone and provincial stakeholders There are two separate stages to implementation the first stage is the actual introduction and implementation of the checklist at the sites There are plans for a measurement piece that will provide sites and the Steering Committee with feedback on the progress of the implementation The second phase of implementation is the long term provincial Safe Surgery Checklist measurement plan which the Steering Committee will implement after development and careful review with surgeons anesthesiologist and nurses from around the province This measurement plan will be communicated to all sites prior to the rollout www albertahealthservices ca AHS Safe Surgery Checklist Manual 18 En Alberta Health Mm Services APPENDIX AHS Safe Surgery Checklist Services Before Induction of Anesthesia EE Alberta Health AHS Safe Surgery Checklist Before Skin Incision Patient family member and or surgical team members have verbally confirmed Patient identity Procedure Site side or level Consent s Known allergies and reactions NPO status Special precautions Malignant hyperthermia Latex Isolation os Other
52. onal months to allow for accrual of a sufficient num ber of patients The sample size was calculated to detect a 20 reduction in complications after the checklist was implemented with a statistical power of 80 and an alpha value of 0 05 OUTCOMES The primary end point was the occurrence of any major complication including death during the period of postoperative hospitalization up to 30 days Complications were defined as they are in the American College of Surgeons National Sur gical Quality Improvement Program acute renal failure bleeding requiring the transfusion of 4 or more units of red cells within the first 72 hours after surgery cardiac arrest requiring cardiopul monary resuscitation coma of 24 hours duration or more deep vein thrombosis myocardial infarc tion unplanned intubation ventilator use for 48 hours or more pneumonia pulmonary embolism stroke major disruption of wound infection of surgical site sepsis septic shock the systemic inflammatory response syndrome unplanned re turn to the operating room vascular graft fail ure and death Urinary tract infection was not considered a major complication A group of phy sician reviewers determined by consensus wheth er postoperative events reported as other com plications qualified as major complications using the Clavien classification for guidance We assessed adherence to a subgroup of six safety measures as an Indicator of proce
53. orm the wrong procedure on the patient When confirmation by the patient is impossible such as in the case of children or incapacitated patients a guardian or family member can assume this role If a guardian or family member is not available the surgical team can confirm that they are all in agreement to the items covered prior to proceeding It is also important at this time to verbally confirm if the patient has any known allergies and what the typical reaction to the allergen is for the patient NPO Status has been placed on the checklist in this section It is the only optional item in this section and can be removed during modification of the checklist if it is deemed non essential information to your local process 2 Special Precautions The individual leading the checklist also completes this next step in the presence of the patient or family member by asking if the patient has any special cautions that may impact the outcome of the procedure For example does the patient know of issues with malignant hyperthermia latex allergies requires isolation precautions etc 3 Weight Kg Recorded on Chart Many dosages are based on weight for pediatric and adult procedures and it is essential that confirmation of the weight has been recorded on the chart 4 Anesthesia Safety and Equipment Check Completed The individual leading the checklist completes this next step by asking the anesthesiologist to verify completion of the anesthesia saf
54. outlined the following guidelines to assist sites in evaluating and modifying the surgical checklist to ensure safety steps inspire effective change and comply with each element key surgical objective for safe surgery Adapted from WHO Guidelines for Safe Surgery 2009 Focused e The Checklist should strive to be concise addressing the most critical issues not adequately checked by other safety mechanisms Five to nine items in each section of Checklist is ideal Brief e The Checklist should take no more than a minute for each section to complete e Amore exhaustive Checklist will impact the flow of care Actionable e Every item on the Checklist must be linked to a specific unambiguous action Verbal e The function of the Checklist is to promote and guide a verbal interaction among team members which is critical to its Success Collaborative e Any effort to modify the Checklist should be in collaboration with representatives from groups who might be involved in using it Actively seeking input from nurses anesthesiologists surgeons and others is important in creating the feeling of ownership which is central to adoption and permanent practice change Tested e Prior to any rollout of a modified Checklist it should be tested in a limited setting e The real time feedback of clinicians is essential to the successful development and implementation Important to test using simulation with may involve simply running through the Ch
55. pe and screen and or crossmatch to ensure that blood products can be made available if required Confirmation of requested radiology should also ensure availability of all essential imaging during the procedure This box is optional and may be removed during modification if not applicable to local practice A decision was made to move the discussion of blood loss to the time out section to avoid increasing the stress to the patient and or family members present It was decided however that it was important to have the confirmation of the crossmatch in the briefing section to save time if it had indeed been missed 7 i www albertahealthservices ca AHS Safe Surgery Checklist Manual 21 Alberta Health WE Services ll Before skin incision TIME OUT Before making the first surgical incision a momentary pause should be taken by the team in order to confirm that several essential safety checks are undertaken These checks must involve all team members 9 All Team Members Have Introduced Themselves by Name and Role Operating room team members may change frequently Effective management of high risk situations requires that all team members understand who each member is and their roles and capabilities A simple introduction can achieve this The individual leading the checklist should ask each person in the room to introduce him or herself by name and role Teams already familiar with each other can confirm that everyone has been in
56. plernentation N ENGL MED 360 5 BEJM G Rt JANUARY 29 2009 Downloaded fom www nejm org on February 20 2009 For personal use only No other uses without permission Copyright 2009 Massachusetts Medical Society All rights reserved www albertahealthservices ca AHS Safe Surgery Checklist Manual 33 ae Alberta Health W Services The NEW ENGLAND JOURNAL of MEDICINE Table 5 Qutcomes before and after Checklist Implementation According to Site No of Patients Enrolled After Unplanned Return to the Operating Room After Surgical Site Infection After Pneumonia Death Alter percent 0 8 1 2 3 6 3 7 1 6 1 7 0 6 0 9 0 3 0 0 2 0 1 9 1 3 02 10 1 7 0 5 1 2 0 0 0 0 24 ll 1 3 Any Complication After Before Before Before Before Before After Before 524 357 497 570 370 496 525 444 3733 598 351 486 4 0 2 0 5 8 3 1 20 5 4 0 9 5 4 l 2 0 1 4 3 2 6 3 6 4 0 4 6 0 6 4 6 25 1 4 3 0 1 8 1 1 2 7 rai 1 3 1 0 1 1 0 8 1 0 1 4 3 0 l 1 4 1 5 0 0 0 3 14 0 6 0 0 1 7 1 0 3 0 8 11 6 TA 13 5 745 21 4 10 1 12 4 7 0 6 4 9 7 5 5 5 5 9 7 8 0 Gl 3 6 11 0 7 0 l 3 4 5 6 f amp Total P value 3 lt 0 001 The most common complications occurring during the first 30 days of hospitalization after the operation are listed Bold type indicates values that were significantly different at P lt 0 05 before and
57. rg on February 20 2009 For personal use only No other uses without permission Copyright 2009 Massachusetts Medical Society All rights reserved www albertahealthservices ca AHS Safe Surgery Checklist Manual 32 ae Alberta Health Mm Services A SURGICAL SAFETY CHECKLIST identity of the patient the operative site and the procedure to be performed and completion of a sponge count at the end of the procedure if an incision was made We recorded whether all six of these safety measures were taken for each patient STATISTICAL ANALYSIS Statistical analyses were performed with the use of the SAS statistical software package version 9 1 SAS Institute To minimize the effect of differ ences in the numbers of patients at each site we standardized the rates of various end points to reflect the proportion of patients from each site These standardized rates were used to compute the frequencies of performance of specified safe ty measures major complications and death at each site before and after implementation of the checklist We used logistic regression analysis to calculate two sided P values for each compari son with site as a fixed effect We used general ized estimating equation methods to test for any effect of clustering according to site We performed additional analyses to test the robustness of our findings including logistic regression analyses in which the presence or ab sence of a data co
58. rgical group finds the surgical checklist does not easily adapt to their situation The Zone Operational leads and the Clinical Quality Support Consultants see Appendix II supporting this initiative through the Implementation Working Group are able to provide sites with insight and draw on the experiences of individuals from AHS that participated in the pilot phase 7 i www albertahealthservices ca AHS Safe Surgery Checklist Manual 11 Alberta Health Mm Services 3 0 Modifying the Checklist AHS has approved a modified version of the WHO Surgical Safety Checklist for use across the province The checklist while intended to be universally applicable may not be a perfect fit for all AHS sites AHS sites or surgical groups may choose to use the AHS Safe Surgery Checklist or modify it to meet the needs of their unique procedures Groups must ensure modifications are consistent with the AHS Guidelines see Section 2 0 and the WHO 10 Essential Objectives for Safe Surgery see Section 1 1 3 1 Guidelines for Modification of AHS Safe Surgery Checklist 1 Modification must include three key stages for communication by the surgical team i e briefing time out and debriefing 2 Sites may add additional items that are deemed essential however removal of any checklist item heading or bullet point is not an option with the following exceptions Optional Briefing Checklist Items NPO status bullet point Relevant and specia
59. rgical teams should pilot the checklist using established quality improvement approaches e g PDSA before full implementation to identify a process that ensures the smooth and efficient running of the checklist 5 Surgical teams sites should pre assign the role of leading the safety checklist to a member s of the Surgical Team a The WHO suggests that a single person be made responsible for performing the safety checklist b Some AHS checklist pilot sites found it preferable to designate the lead of the checklist as follows Briefing Anesthesia Time Out Surgeons De Briefing Nursing 7 i www albertahealthservices ca AHS Safe Surgery Checklist Manual 10 Alberta Health Mm Services c Alternatively other sites have designated the lead for the checklist according to subsections of checklist appropriate to their function i e anesthesiologist will verbally review all portions of the checklist related to anesthesiology etc 6 The AHS Safe Surgery Checklist is designed to ensure the BOLD headings and bullet points are communicated verbally by the individual leading the checklist or portion of and verbally confirmed with the appropriate team member s to ensure that the key actions have been completed The non bold bullet points serve as triggers for discussion 7 Itis appropriate for the team member leading the checklist to skip a heading or bullet point on the checklist ONLY if it is NOT applicable
60. rsonnel involved in the procedure Alternatively this can apply to any physician and support staff if the procedure occurs outside of an operating room setting e g procedure rooms within the Emergency Department Invasive Radiology etc Patient Refers to those people identified as patient client and or resident who are receiving or registered to receive medical treatment which may involve surgical intervention Family For the purpose of this manual a family member may include a spouse parent sibling child guardian or agent that have legal standing to provide consent on behalf of the patient for a medical procedure 7 i www albertahealthservices ca AHS Safe Surgery Checklist Manual 5 En Alberta Health Mm Services 1 1 Ten Essential Objectives for Safe Surgery To assist surgical teams in reducing the number of preventable surgical complications the WHO as part of their Safe Surgery Saves Lives campaign have identified ten essential objectives for safe surgery These objectives were developed in consultation with surgeons anesthesiologists nurses patient safety experts and patients from around the world WHO Ten Essential Objectives for Safe Surgery Reference adapted from WHO Guidelines for Safe Surgery 2009 1 The team will operate on the correct patient at the correct site on the patient s body 2 The team will use methods known to prevent harm from administration of anesthesia
61. simply a communication tool to trigger members of the surgical team to ensure critical safety checks are completed at key stages in the procedure Q Will all surgical facilities in the province be using the same checklist A All AHS sites will be provided with the AHS Safe Surgery Checklist but sites should ensure the checklist is suitable for their particular environment to enable successful implementation The checklist can be adjusted based on predetermined modification criteria see Section 3 1 to suit the needs of the sites to help ensure the safety of their patients the flow of surgical procedures and the commitment of the entire surgical team 7 i www albertahealthservices ca AHS Safe Surgery Checklist Manual 8 Alberta Health WE Services Q Who should be in charge of leading the surgical checklist in the OR surgical suite A AHS recommends that the sites or surgical groups determine who should be leading the surgical checklist prior to implementation This decision should be based on the individual particulars of the site environment Sites participating with the piloting of the checklist in Alberta had different successes with different approaches Some groups felt the best success came with the surgeon leading the entire checklist Other pilot groups assigned each section of the checklist to different groups while others pre identified specific portions of each section by function i e the anesthesiologist lead
62. son W et al The National Veterans Administration ur gical Risk Study risk adjustment tor the comparative assessment of the quality ot surgical care J Am Coll Surg 1995 180 519 31 18 Dindo D Demartines N Clavien PA Classification of surgical complications a new proposal with evaluation in a co hort of 6336 patients and results of a sur vey Ann sarg 200 2402 205 13 19 Dleiss JL Levin B Paik MC Statistical methods for rates and proportions 3rd ed Hoboken Nh John Wiley 2003 20 Sexton JB Makary MA Tersigni AR et al Teamwork in the operating room frontline perspectives among hospitals and operating room personnel Anesthe siology 205 105387 7 54 21 Makary MA Sexton JB Preischlag JA et al Operating room teamwork among physicians and nurses teamwork in the eye of the beholder J Am Coll Surg 2006 203 Fd 6 52 22 Platt E Zaleznik OF Hopkins CC et al Perioperative antibiotic prophylaxis for herniorchaphy and breast surgery N Engl J Med 1990 327 153 60 73 Austin TW Coles JC Burnett R Gold bach M Aortocoronary bypass procedures and sternomiy infections a study of anti staphylococcal prophylaxis Can J Surg FEELERS E ta i 24 Baum ML Anish DS Chalmers TC Sacks HS Smith H Jr Fagerstrom RM A survey of clinical trials of antibiotic prophylaxis in colon surgery evidence against further use of no trearment con trols W Engl Med 1991 305 795 9 25 Bernard HR Cole WR The prophy
63. ss adher ence The six measures were the objective evalu ation and documentation of the status of the patient s airway before administration of the anes thetic the use of pulse oximetry at the time of initiation of anesthesia the presence of at least two peripheral intravenous catheters or a central venous catheter before incision in cases involving an estimated blood loss of 500 ml or more the administration of prophylactic antibiotics within 60 minutes before incision except in the case of preexisting infection a procedure not involving incision or a contaminated operative field oral confirmation immediately before incision of the Table 3 Surgical Safety Policies in Place at Participating Hospitals before the Study Standard Plan for Routine Administration Intravenous Access of Prophylactic Antibiotics for Cases of High in Operating Room Blood Loss Routine Oral Confirmation Intraoperative Monitoring with Site No Pulse Oximetry of Patient s Identity and Surgical Site in Operating Room Formal Team Briefing Preoperative Postoperative Yes Yes Yes No No No Yes No Yes No No No Yes No Yes No No No Yes Yes Yes No No No No No No No No No No No No No No No No No Ne Neo Neo Neo So sy Ja A Se a hi Sites 1 through 4 are located in high income countries sites 5 through amp are located in low or middle income countries 494 NENGLIMED 360 NEJM ORG JANUARY 29 2009 Downloaded from www nejm o
64. tation of all clinical team members involved in surgical procedures e Identify a core group of people who are enthusiastic about the checklist while trying to involve at least one member from each of the clinical disciplines e At the early stages of planning and implementation work with those who are interested and willing to participate rather than trying to change the most resistant people e Set up regular meeting schedule for the team 7 Review Support Material e Video links and support material to understand how to use the checklist appropriately are available at the following websites o http Awww who int patientsafety safesurgery en o http www ihi org IHI Programs ImprovementMap WHOSurgicalSafetyChecklist htm o http www patientsafetyinstitute ca English toolsResources sss l Pages default aspx 7 i www albertahealthservices ca AHS Safe Surgery Checklist Manual 14 Alberta Health M Services 8 Adopt a Quality Improvement Strategy That Will Work for the Site Service i Start Small Then Expand e Start with a single operating room department and or surgeon o It was noted by sites participating in the WHO study that sites that tried to implement the checklist in multiple operating rooms simultaneously faced the most resistance and had the most trouble convincing staff to use the checklist effectively o Consider using an approach such as PDSA cycles that will allow the team to test the suggested changes and t
65. the AHS Safe Surgery Checklist A YES AHS will be establishing a support system for individual sites during the implementation phase There will be Quality and Operational staff that will be identified within zones see Appendix III to mentor groups provide support to answer questions and communicate issues to the provincial steering committee for action Q How will we know if implementing the AHS Safe Surgery Checklist has made a difference A AHS is developing a measurement dashboard to support the implementation and sustainability of the surgical checklist which will measure usage of the checklist and the impact on outcome to patients The measurement plan will be communicated to all AHS sites when it is completed The plan will be relevant to sites using either paper OR charting or electronic patient management systems Outcome measures are being developed with input by healthcare professionals from around the province to ensure appropriate metrics are in place so surgical teams understand the impact of the checklist on improving the safety of patients undergoing surgical procedures 7 i www albertahealthservices ca AHS Safe Surgery Checklist Manual 9 Alberta Health WE Services 2 0 Guidelines for Use of the AHS Safe Surgery Checklist The following are a set of guidelines developed to assist AHS sites in determining how to use the surgical checklist For full discussion of the rationale and use of each item on the AHS S
66. the procedure which may be longer or shorter than expected due to issues unique to the procedure or patient e A review of the Risk of gt 500 mL blood loss 7 mL Kg in children is one of the WHO 10 essential objectives for safe surgery and is a requirement for all surgical checklist Large volume blood loss is among the most common and important dangers for surgical patients with risk of hypovolemic shock escalating when blood loss exceeds 500 mL 7 mL kg in children Adequate preparation and resuscitation may mitigate consequences considerably Surgeons may not consistently communicate the risk of blood loss to anesthesia and nursing staff Therefore if 7 i www albertahealthservices ca AHS Safe Surgery Checklist Manual 22 Alberta Health Mm Services the specific risk of major blood loss associated with the patient or the procedure is unknown or unclear the surgeon can discuss the situation with the team prior to commencement b Anesthesiologist Review The anesthesiologist s review should involve the following e Are there any patient specific concerns e ls there adequate intravenous access and fluid planned If there is a significant risk of a greater than 500 mL blood loss it is highly recommended that at least two large bore intravenous lines or a central venous catheter be placed prior to skin incision In addition the team should confirm the availability of fluids or blood c Nursing Review The nurse
67. tions at OR staff meetings e Email reminders to members of the surgical team before the start of the trial pilot e Posting and sharing the New England Journal of Medicine article see Appendix I e Memos from hospital and medical leaders supporting and endorsing the surgical checklist 4 5 Key Communication Messages to Assist with Implementation and Engagement 1 Each individual portion of the AHS Safe Surgery Checklist has been included based on clinical evidence or expert opinion gathered from around the province The inclusions of specific portions of the checklist have been incorporated to reduce the likelinood of serious avoidable surgical harm 2 The AHS Safe Surgery Checklist was designed for simplicity and brevity Many of these steps are already accepted as routine practice in facilities around the world but the checklist brings all of them together in a forum of open communication 3 Successful implementation requires adapting the checklist to local routines and expectations 4 The AHS Safe Surgery Checklist is meant to be used as a communication tool to provide teams with a simple efficient set of high priority checks for improving communication which will help to ensure that the safety of the patient is a top priority in every single operation that is done 4 6 Physician Engagement Strategies Physician engagement is a critical aspect and key success factor in the implementing of any improvement initiative in healthcare T
68. troduced If additional staff have rotated into the operating room since the last operation they should introduce themselves This introduction should include students or other personnel 10 Surgeon Anesthesiologist and Nurse Have Verbally Confirmed Patient Procedure Site The individual leading the checklist will request all team members to stop and verbally reconfirm e name of the patient e procedure to be performed e site of surgery For example the circulating nurse might announce Before we make the skin incision does everyone agree that this is patient X undergoing a right inguinal hernia repair The anesthesiologist surgeon and circulating nurse should explicitly and individually confirm agreement 11 Anticipated Critical Events To ensure communication of critical patient issues the individual leading the checklist leads a swift discussion among the surgeon anesthesia and nursing staff of critical dangers and operative plans The order of discussion does not matter but each clinical discipline should provide information and communicate concerns a Surgeon Review The surgeon s review should involve the following e A review of the critical steps associated with the procedure that may result in injury or risk of morbidity This is also a chance to review steps that might require special equipment implants or preparations e Duration of procedure is to ensure that all team members understand the expected length of
69. while protecting the patient from pain 3 The team will recognize and effectively prepare for life threatening loss of airway or respiratory function 4 The team will recognize and effectively prepare for risk of high blood loss 9n The team will avoid inducing an allergic or adverse drug reaction for which the patient is known to be at significant risk The team will consistently use methods known to minimize the risk for surgical site infection The team will prevent inadvertent retention of instruments and sponges in surgical wounds The team will secure and accurately identify all surgical specimens O p eS The team will effectively communicate and exchange critical information for the safe conduct of the operation 10 Hospitals and public health systems will establish routine surveillance of surgical capacity volume and results AHS has adopted these ten WHO objectives as part of the AHS Safe Surgery Checklist to be introduced to all AHS sites to help ensure the quality and safety provided to patients within surgical services The implementation will also support AHS sites in compliance with the anticipated new Accreditation Canada Required Organizational Practices ROP Surgical Checklist standard for introduction in 2011 The aim of the checklist is to reinforce accepted safety practices and foster better communication and teamwork between clinical disciplines Every surgical team can improve the safety and quality of
70. ylor M D and Atul A Gawande M D M P H for the Safe Surgery Saves Lives Study Group ABSTRACT BACKGROUND Surgery has become an integral part of global health care with an estimated 234 million operations performed yearly Surgical complications are common and often preventable We hypothesized that a program to implement a 19 irem surgical safety checklist designed to improve team communication and consistency of care would reduce complications and deaths associated with surgery METHODS Between October 2007 and September 2008 eight hospitals in eight cities Toronto Canada New Delhi India Amman Jordan Auckland New Zealand Manila Phil ippines Ifakara Tanzania London England and Seattle WA representing a vari ety of economic circumstances and diverse populations of patients participated in the World Health Organization s Safe Surgery Saves Lives program We prospec tively collected data on clinical processes and outcomes from 3733 consecutively enrolled patients 16 years of age or older who were undergoing noncardiac surgery We subsequently collected data on 3955 consecutively enrolled patients after the introduction of the Surgical Safety Checklist The primary end point was the rate of complications including death during hospitalization within the first 30 days after the operation RESULTS The rate of death was 1 5 before the checklist was introduced and declined to 0 8 afterward P 0 003 Inpatient compli

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