• Print This
• Select Text Size:
• Comments
• 

Tell most nurses there’s another checklist to improve patient safety and they will probably yawn and respond, “So what’s new?” But a new OR safety checklist has proven so effective in saving lives (really) that the World Health Organization is asking every hospital in the country to try it at least once by April 1.

So what makes this particular checklist different? Most checklists in use today tend to be silent paper exercises in which a lone nurse checks off boxes. In contrast, the WHO Surgical Safety Checklist is a tool of communication and functions as a list of team talking points.

“The most important thing this checklist does is make people think as a team about all the steps that they need to ensure will happen,” says Atul Gawande, MD, coauthor of the checklist study and a surgeon at Brigham and Women’s Hospital and associate professor at the Harvard School of Public Health in Boston, Mass.

This “checklist” is really a verbal conversation, according to Susana Novak, RN, associate director of nursing for Perioperative Services at Brooklyn’s Coney Island Hospital, one of the first hospitals in the New York City Health and Hospitals Corporation system to pilot the checklist.

“One person, usually a nurse, takes the lead, but that nurse cannot do all the talking with everyone else just nodding their heads,” says Novak. “Everyone on the team has to verbally respond, including physicians, anesthesia, and other nurses.”

The patient is also considered a team member and active participant in the checklist conversation. During the pre-procedural portion of the checklist, he or she must verbally confirm his or her identity, the surgical site, the procedure, and give consent.

Becoming a High-Reliability Industry

Evidence from high-reliability industries, such as nuclear power and aviation, has shown that a verbal check is more likely than a written check to capture and prevent errors, according to Alex B. Haynes, MD, MPH, lead author of the study and researcher at Harvard School of Public Health. In fact, the checklist doesn’t need to be documented on a piece of paper at all. The checklist conversation can be adapted to suit the needs and resources of individual facilities and can simply be followed through with a poster visibly displayed in the OR.

“It’s not intended to be a form of documentation or regulation,” says Haynes, who is also a surgeon at Massachusetts General Hospital in Boston. He adds that organizations do have the option to adapt it to serve that purpose if they choose. For example, hospitals in the HHC system have chosen to incorporate the checklist conversation into their documentation system. It has also been adapted for use during all clinic, ambulatory, and inhouse surgical procedures, such as inserting chest tubes and central lines.

Making It Work

Adapting and implementing the WHO Surgical Safety Checklist can require hurdling over some obstacles.

“The biggest challenge we had was getting everybody on board with the verbal part of the checklist,” says Elaine Hylton, RN, associate director for the OR at Lincoln Medical and Mental Health Center, Brooklyn, another piloting hospital in the NYC public hospital system.

“Many of us thought the checklist conversation was just one more thing we had to do to get a case started,” says Jodi Bloom, RN, BSN, CNOR, staff nurse in the OR at the University of Washington Medical Center, the only U.S. hospital that participated in the checklist study. “Now we think it’s an invaluable tool. It collectively forces everyone in the room to pay attention, focus on the patient, discuss the patient, and be on the same page.”

The checklist conversation can take as little as two minutes to complete. “If you try it with one case. you learn very quickly how to best adapt it to your practice,” says Bloom. “Our surgical teams were accustomed to performing time-outs, and this came to be incorporated into our practice as an extended time-out. Now it’s become innate.”

Arlinda Racaza, RN, assistant director of nursing for the OR at Lincoln, says a key to success is to test the checklist on a small scale first. At Lincoln, the checklist was first used in one room and then expanded to all procedures in all eight rooms.

Successful implementation also includes tapping into the enthusiasm of people who are open to the idea and beginning with cases from a surgeon who champions it. Racaza also recommends presenting the concept to the entire OR staff before implementation and asking for and incorporating their input in adapting the list.

“It is a change for everyone,” says Racaza. “But it is a change for the safety of the patient.”

Creating Your Own Checklist

The OR team at Winthrop-University Hospital in Mineola, N.Y., has not adapted the WHO’s checklist, but uses its own checklist and process that incorporates many of the same elements, according to Noyes Harrigan, RN, MPA, CNOR, OR clinical instructor.

OR nurses at Winthrop have been active in creating and modifying the surgical safety checklist since 1999. The checklist has evolved over the years to adapt to changing standards, resources, and to incorporate all necessary safety checks.

Following the National Patient Safety Goals from the Joint Commission, the entire team must stop what they are doing to give their attention to and actively participate in a verbal safety discussion. The discussion is held during a time-out immediately before starting a surgical procedure and is initiated by a circulating nurse. Similar to the WHO’s checklist, Winthrop’s time-out reviews such vital safety elements as verifying patient identity, that the correct site and side have been marked, that an accurate consent form is signed, and that relevant radiology images are properly labeled and displayed. The team also confirms the need to administer antibiotics and ensures that necessary implants, devices, and special equipment are available.

“We ensure that everyone is in agreement that all our ducks are in a row before the procedure can be started safely,” says Harrigan.

Harrigan adds that the key to ensuring that a surgical safety checklist does not become another piece of paper and truly remains a tool that facilitates a team discussion is for managers to perform regular audits.

“You have to go into the room and listen for it, to ensure that everyone is consistently following through.”

---

Cathy Spader, RN, is a contributing writer to Nursing Spectrum.

To comment, E-mail editorNY@nursingspectrum.com.

Reader Comments

You must adhere to the Terms of Service and Community Rules for Nurse.com when posting comments. Please do not post disparaging or offensive remarks. You may use links in your post.

Be the first to comment!