The Checklist Protocol

A year ago, a young female footballer lost her leg and subsequently her life following a minor orthopedic procedure for a torn ligament in her knee, the reason was someone forgot to remove the tourniquet applied as part of the procedure. The incident sent shockwaves across the medical fraternity and a huge public and media outcry followed. Subsequent inquiries revealed failure to recognize the complication postoperative by the surgical team and the ward staff as well. The family lost an aspiring footballer and a lively, young daughter, and the hospital including the surgeon, their reputation as well. Tales like these abound in the medical and surgical field where years of hard work, dedication, skill, and reputation are lost in a single such incident. Forgotten instruments,sponges,pads within the abdominal or thoracic cavities,operating on the wrong patient,wrong limb or removal of wrong organs or limb do continue to happen and it’s no use blaming any particular individual, instead it’s the whole system that is to be blamed. Atul Gawande, American Surgeon and Author of the book “The check list Manifesto” writes that “The number of Americans getting operated is around 50 million per year and there are about 1,50,000 deaths (0.4% -0.8%) and major complications (3%-17%) following surgery every year and about 50% of these deaths and major complications could have been avoided”.[1] However skilled and trained these surgeons are still mistakes do happen. How to avoid such mistakes and unwanted complications is a difficult question and a big challenge to the Doctors and medical administrators alike. THE BREAK THROUGH… A critical care specialist and often described by many as a “genius” in public health care, Dr.Peter Pronovost from John Hopkins hospital was investigating the large number of cases with central line infections and associated complications in the I.C.U and ways to prevent this, so he wrote up a simple checklist which included tasks during insertion of these lines like handwashing with soap, skin prep with Chlorhexidine, sterile drapes, wearing of sterile gown, cap, masks by the intensivists and application of sterile dressing over these access sites etc, Dr. Pronovost instructed the sisters to observe the Doctors and to make sure that the Doctors followed the checklist, though initially the Doctors found it a little bit difficult to obey the staffs instructions after one year, Dr.Pronovost found that the “ten -day line infection” rate fell from 11% to 0% and after observing it for a longer period in that hospital he found that the checklist prevented 43 infections, 8 deaths and saved nearly 2 million Dollors in costs.All because of this small check-list! In 2003, the Michigan Health and Hospital association approached Pronovost regarding testing his checklist throughout the state’s ICUs, in what would later be known as the ‘Key stone initiative” checklists were implemented through out the ICUs in the state and in December 2006 the keystone initiative published it’s findings in the NEJM December 2006,[2] within the first 3 months of the project the central line infection rate in Michigan’s ICUs fell by 66%,the hospitals saved more than 1500 lives and an estimated $175 million in costs, this success was achieved by following a simple check list. The concept of a checklist first emerged from the aviation industry in the early 1930’s where pilots have to go through an elaborate pretake-off checklist regarding the various systems within the aircraft for a safe flight, checklists do exist in other industries like construction, restaurants etc but the idea of a medical checklist eluded many. THE WHO CHECKLIST The WHO impressed with the checklist concept held a meeting in Geneva, Dr. Atul Gawande, many doctors, administrators, and patients as well, attended this meeting which discussed the need to evolve a proper checklist to be followed before and after surgery, a model checklist evolved and between October 2007 and September 2008, the “WHO safe surgery saves lives” checklist was tested in eight different hospitals in eight cities including New Delhi (India), Auckland (New Zealand), Manilla (Philippines), Ifacara (Tanzania), London (England), Seattle (Washington), Amman (Jordon), and Toronto (Canada) from advanced centers to third-world countries in Asia and Africa as well, representing a variety of economical and diverse population. Dr. Atul Gawande and his team visited each of these eight centers to get a first-hand experience in monitoring the implementation of the WHO checklist [Table 1].Table 1The data on clinical processes and outcomes from 3733 consecutive patients 16 years and above who underwent noncardiac surgery and 3955 consecutive patients after the introduction of the checklist was introduced were analyzed. They studied the rate of complications including death during hospitalization within the first 30 days after the operation; the rate of death was 1.5% before the checklist was implemented and declined to 0.8% afterward. In-patient complications occurred in 11% at baseline which declined to 7% after introduction of checklist. Postoperative complications fell by 36% and death rates by 47%. The results astounded the investigators so much that they published it as a special article in the New England Journal of Medicine, January 2009 issue[3] and subsequently, the WHO checklist was adapted worldwide and has been making significant contributions toward reducing surgery-related complications. It is very easy to follow and includes presurgical and postsurgical items that need to be ticked off by the Operation theatre (OT) staff themselves to ensure a safe and smooth surgery. Following the tragic death of the young footballer, the Tamil Nadu Government instituted a high-level committee which held meetings with various specialists, caretakers, and administrators throughout the state and made it mandatory to attach and maintain the WHO checklist in all surgical case sheets in the state and its making an impact. Today it’s prudent that we in our specialty to evolve checklists for many of the common procedures including diagnostic and therapeutic interventions both open and endovascular including pre- and post-procedural work-ups so as to minimize if not totally avoid the complications which may be as simple as drug or contrast-related allergies to access related complications so that we can deliver quality as well as safe medical care to our patients and avoid unnecessary, unwanted problems.

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