Surgical Safety Checklist: Is all good?

In an effort to providing safe surgical care, the World Health Organization (WHO) (2009) recommended a checklist, the “Surgical Safety Checklist” (SSCL), intended to be applied globally, so as to significantly reduce the rate of surgical complications. The SSCL identifies a series of checks needed to be performed in any operating room so as to reinforce the safety practices, avoid surgical infection, and improve communication as well as team work between surgeons, anesthetists, and nursing staff.[1] There are previous reports in literature stating that in hospitals where SSCL is effectively implemented, there is a significant decrease in complication rate and death rates.[2] The SSCL has assumed an integral and vital part of safe surgical practices in most parts of the developed countries.

Data from Indian hospitals are relatively scarce. Except for a few tertiary hospitals across India, the majority of the hospitals still either do not use SSCL or are unaware of it. In places where it has been brought into practice, the compliance rate has been found to be low. A recent review[3] on SSCL practices highlighted the hurdles commonly encountered to successful implementation of SSCL. The main challenges stated by the authors include the huge workload, with a large number of operations being carried out daily and limited availability of staff personnel. Most of the operation theater staff and surgeons consider it to be an additional burden, causing unnecessary delays. Another hindrance to nationwide acceptance and implementation of SSCL is our mental barrier rather than any functional issues with the checklist.[4] There is a need to overcome the communication barrier that exists between the operating team members and the patient.

Since a growing evidence points toward improved patient outcomes following application of SSCL, certain strategies that have led to an increase in the acceptance and adoption of checklist into daily practice warrant attention in the developing countries. The application of SSCL relies on interdisciplinary teamwork, and hence having all stakeholders such as anesthesiologists, surgeons, and nursing staff on board as a team is the key to success. Leadership support, where the department chief acts a member of the implementation team, was shown to increase the success rate of compliance with SSCL. Team work approach can be made more effective by team training. Another important step in this direction is to conduct regular audits and entertain feedbacks in hospitals where SSCL use has been implemented. In this issue of the journal, Ambulkar et al.[5] have brought forth an audit of quality of implementation of WHO SSCL 5 years after its introduction in a tertiary care high-volume cancer institution of India. The authors found that even after 5 years of its introduction in their institute, the quality of implementation and compliance was suboptimal. Compliance was found to be 100%, 78%, and 76.5% for the first, second, and third parts of SSCL, respectively. The level of interaction between all the team members was found to be poor, with it being present in only 52% of the cases. To further improve the quality of checklist implementation and increase compliance, the authors have suggested regular education and training of health professionals, training sessions, active leadership, multidisciplinary communication, and constant feedback, especially from end-users.

The SSCL is an extremely simple checklist that hardly takes any time to complete. It is important to realize that no time spent or effort put in following SSCL is greater than the positive impact it has on patient safety and outcome. Hospital administration should show the way forward and establish initiatives to support and promote the SSCL use. Awareness about patient safety, providing a clear rationale for the use of checklists can be reemphasized periodically by educational tools such as videos, PowerPoint presentation, and use of templates. Further minor adjustments can be made in the checklist to best suit the local needs and culture of the operating rooms, thus making it more acceptable.[6] Robust data through properly conducted trials, highlighting teamwork efforts, will further bridge the gap between protocols and practice.

To summarize, the actual impact of SSCL on patient outcome varies with the effectiveness of its implementation in each institution. SSCL is a simple yet “powerful tool” and needs to be strictly incorporated for enhancing patient safety into our routine practice. This is, however, not possible without having sincere commitment toward the belief that safety during surgery is a priority.