According to World Health Organisation (WHO), while surgical procedures are intended to save lives, unsafe surgical care can cause substantial harm. Given the ubiquity of surgery, this has signiﬁcant implications:
- in industrialized countries, nearly half of all adverse events in hospitalized patients are related to surgical care;
- at least half of the cases in which surgery led to harm are considered preventable;
- Mortality from general anaesthesia alone is reported to be as high as one in 150 in some parts of sub-Saharan Africa.
In a survey of 1050 hand surgeons, approximately 20 % of them admitted to have performed wrong site surgery at least once. Lack of good communication between team members involved in surgery may result in complications and has been reported to be a major cause of approximately 70 % of adverse events (Joint Commission. Sentinal events statistics – December 31, 2006).
An important concept recently introduced by WHO, has been the use of checklists to reduce the numbers of these avoidable complications. Checklists have been used previously in many fields like aviation and manufacturing to improve safety and efficiency. However, the wide use of checklists in surgery has only started recently. WHO’s multinational initiative in 2007, entitled ‘Safe Surgery Saves Lives’ clearly demonstrated a decrease in morbidity and mortality related to surgery. .
According to Dr SamiranNundy, Author of the study and Emeritus Consultant, Department of Surgical Gastroenterology & Liver Transplantation, Sir Ganga Ram Hospital (SGRH), “The implementation of a surgical safety checklist is said to minimize postoperative surgical complications. However, to our knowledge, no randomised controlled study has been done on the influence of checklists on postoperative outcomes in a developing country.”
To evaluate the impact of surgical check list, Department of Gastro-intestinal Surgery, SGRH decided to perform a prospective, randomized and controlled trial in 700 consecutive patients undergoing a surgical procedure in GI Surgery unit between February 2012 and April 2013. Two groups were made- in both the groups, a hospital checklist (used in all patients before operation in our hospital) was filled in by the nurses. In 350 patients, in addition to the hospital checklist, a modified WHO checklist was implemented which was filled in by a surgical resident (Rc arm)and the results were compared with a control group of another 350 patients (Rn arm).
Dr Nundy further added, “We used the checklist on three occasions: before anaesthesia (sign in), before the skin incision (time out) and before the patient was shifted out of the operating room (sign out).”
Agreeing to Dr NeerajChaudhary, corresponding author of study & clinical assistant, Department of Surgical Gastroenterology & Liver Transplantation Sir Ganga Ram Hospital “ In this prospective randomized controlled study, the implementation of a modified WHO surgical safety checklist was associated with a decrease in mortality and number of complications. The mortality was significantly lower in the modified WHO checklist group (Rc Arm) which had a mortality rate of 5.7 % compared to 10 % in the group where this checklist was not used (Rn Arm). This is the first study, to our knowledge, which has shown improved results with checklist implementation in a prospective, randomized controlled trial from a developing country. Improved results after checklists have also been shown by previous studies, but all of these were in a cohort setting and from the developed world.”
Dr Chaudhary further added,“Overall and higher grade complications in the modified WHO checklist group were also lower than the other group in which this checklist was not used. Bleeding- and wound-related complications decreased in the intervention group which could be due to better coordination between the teams involved in providing safety. “
Our results are comparable to another large prospective study done in 2009 and published in New England Journal of Medicine wherein , using WHO checklist in eight hospitals in different cities across the globe over 1 year on about 4000 patients, there was substantial reduction in both mortality as well as complication rate . Similarly, a study in the Netherlands, published in New England Journal of Medicine in 2010, using more parameters in the checklist also documented reductions in mortality and morbidity.
Conferring to Dr Nundyfurther said, “Surgical complications are a major cause of morbidity and mortality and also pose a major financial burden to patients and providers. This is especially relevant in a developing country like India where there is a lack of resources and more than three fourths of the population pays out of their pocket for health expenses. We have found in a prospective randomized study in a gastrointestinal and HPB surgical department that implementation of a checklist significantly reduces postoperative morbidity and mortality. “
“We suggest therefore that strict implementation of the WHO checklist should be made mandatory in India and the developing world.” added Dr Nundy