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Checklists and Safety Improvements
EDITORIAL
Checklists and Safety Improvements PATRICIA C. SEIFERT, RN, MSN, CNOR, CRNFA, FAAN, EDITOR-IN-CHIEF
I
n a December 2007 article in The New Yorker magazine,1 Atul Gawande, MD, describes a checklist developed by Peter Pronovost, MD, PhD, in 2001. The checklist was introduced into a critical care unit to decrease the incidence of catheterrelated bloodstream infections, which are also a concern in surgical patients who require central line insertion. According to Dr Gawande, the steps in Dr Pronovost’s checklist included 1) hand washing with soap; 2) using chlorhexidine to cleanse the patient’s skin; 3) fully covering the patient with sterile drapes; 4) wearing a hat, mask, sterile gown and gloves; and 5) applying sterile dressings to the catheter insertion site. Dr Gawande describes the initial resistance by medical and nursing staff members to the use of this procedural tool. Clinicians’ objections included concerns that the use of the checklist would delay patient care, that it would not reduce medical error, and that it would annoy physicians and administrators. Dr Pronovost persisted, and in 2003, the checklist was tested in 103 intensive care units (ICUs). The study’s results, published in 2006,2 showed a dramatic reduction in the number of catheterrelated infections. Within three months, infections decreased from 2.7 infections to zero infections per 1,000 catheter days. Dr Pronovost’s findings demonstrated not only a reduction in central line infections but also that implementation of a specific and deliberate process would improve patient safety. It is significant that Dr Pronovost and his coauthors noted that “. . . a
© AORN, Inc, 2009
checklist was used to ensure adherence to infection control practices [and] providers were stopped (in nonemergency situations) if these practices were not being followed. . . .”2(p2726) These two considerations—use of a checklist and cessation of activity if the steps of the process are not enacted—have become cornerstones of Use of a checklist the safety movement.
SURGICAL SAFETY CHECKLISTS
and
cessation of activity if the steps of the
For perioperative patients, the introduction of process have not a standardized procedure employing a checkbeen followed have list to prevent wrong site, wrong procedure, become cornerstones and wrong person surgery was generated from of the safety a summit convened by the Joint Commission in movement. 2003.3 The resulting Universal Protocol established by the Joint Commission became part of its health care organization accreditation process in 2004.3,4 More recently, the World Health Organization (WHO) introduced the Surgical Safety Checklist as part of its Safe Surgery Saves Lives program5 to reduce surgical complications on a global scale. The checklist specifies actions in three phases of surgery: • before induction of anesthesia (ie, Sign In); • before the skin incision (ie, Time Out); and • before the patient leaves the OR (ie, Sign Out).5 In a prospective study performed in
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APRIL 2009, VOL 89, NO 4
eight countries between October 2007 and September 2008, researchers using the WHO checklist demonstrated reductions in both the death rate (from 1.5% to 0.8%) and complications rate (from 11% to 7%).6 Although not all errors can be prevented, it is estimated that more than half of surgical complications are preventable.6,7 Given the substantial evidence demonstrated by Dr Gawande, Dr Pronovost, and others6 that checklists improve safety, why are there not fewer errors?
BARRIERS
TO
SAFE CARE
are ridiculed for wanting to adhere to a safety checklist and perform a time out or are told that “it’s not necessary because I know what I’m doing.” These barriers and other forms of resistance to following established procedures should not be tolerated. Individuals—physicians, nurses, or other personnel—cannot choose to be noncompliant and deviate from established and proven procedures that reduce error. All members of the team are important to patient care, and each member must be able to function in an environment that encourages compliance All members of the with practices that promote safe patient care. surgical team are
Some insights come from both media representatives and health care professionals. For example, writing on the INVOLVING ALL important to patient Boston Globe web site about MEMBERS OF THE TEAM an article by Haynes and Teamwork is a basic tenet care, and each member colleagues6 that discusses of safety. Perhaps what is the WHO checklist, Liz needed is a redefinition of must be able to Kowalczyk8 mentions OR staff what constitutes team memmembers’ concerns about bership. The importance of function in an wasting time with the checkadministrative support was list when there is pressure to addressed by Dr Gawande, environment that turn over an OR. In interviewHaynes et al, and also by Paul ing the study’s authors, Levy, president and chief encourages compliance Kowalczyk notes that they executive officer of Beth Israel “said it takes a strong commitDeaconess Medical Center in with practices that Boston, Massachusetts. On his ment by hospital leadership to blog of January 15, 2009, Levy adopt this type of change.”8 promote safe care. When there is greater pressure writes that when he chalto focus on turnover time lenged hospital administrarather than checklist time, tors about using the checklist, there is not only an increased “the response [was] silence.”11 risk for error but also greater potential for frusSilence is not an option. Active support by tration among staff members. health care facility leaders is critical to the sucFrustration on the part of caregivers can cessful implementation of a safety checklist. lead to moral distress—the inability to act in an Given their influence in creating and mainethical manner because of obstacles within a taining a culture of safety, health care execusituation.9 Pauline Chen, MD, writing in the tives are de facto members of the surgical New York Times,10 describes a nurse colleague team. Administrators may not be physically who felt conflicted because she was unable to present during a time out, but their support express her concerns about patient care without and a “no exceptions” commitment to combeing labeled unprofessional by supervisors or pleting a safety checklist certainly constitute “out of line” by physicians,10 and at the same fulfillment of team membership criteria. Patients are also team members. Perioperatime she felt, “If I don’t say anything . . . the tive nurses can play an important role by patient might suffer.”10 Perioperative nurses educating administrators and patients, as face barriers to doing the right thing when they
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Editorial
APRIL 2009, VOL 89, NO 4
well as recalcitrant surgical colleagues, about the positive results of using checklists. The benefits include not only better patient outcomes, but also fewer legal liabilities, greater staff satisfaction and reduced staff turnover, and positive financial returns. It seems improbable, but something as simple as a checklist can have profound effects. Editor’s note: The Universal Protocol is a trademark of the Joint Commission, Oakbrook Terrace, IL.
REFERENCES 1. Gawande A. The checklist. The New Yorker. December 10, 2007. http://www.newyorker.com /reporting/2007/12/10/071210fa_fact_gawande. Accessed February 14, 2009. 2. Pronovost P, Needham D, Berenholtz S, et al. An intervention to decrease catheter-related bloodstream infections in the ICU. New Engl J Med. 2006; 355(26):2725-2732. 3. Mulloy DF, Hughes RG. Wrong-site surgery: a preventable medical error. In: Hughes RG, ed. Patient Safety and Quality: An Evidence-Based Handbook for Nurses. Vol 2. [AHRQ Publication Number 08-0043]. Rockville, MD: Agency for Healthcare Research and Quality; 2008:2-381–2-395. http://www.ahrq.gov/qual/nurseshdbk. Accessed February 14, 2009. 4. Universal Protocol. The Joint Commission. http://www.jointcommission.org/PatientSafety /UniversalProtocol. Accessed February 14, 2009. 5. Surgical Safety Checklist. World Health Organi-
zation. http://www.who.int/patientsafety/safe surgery/tools_resources/SSSL_Checklist_finalJun08 .pdf. Accessed February 14, 2009. 6. Haynes AB, Weiser TG, Berry WR, et al; Safe Surgery Saves Lives Study Group. A surgical safety checklist to reduce morbidity and mortality in a global population. New Engl J Med. 2009;360(5):491499. Epub January 14, 2009. http://content.nejm.org /cgi/content/full/NEJMsa0810119. Accessed February 14, 2009. 7. Institute of Medicine. Kohn LT, Corrigan JM, Donaldson MS, eds. To Err Is Human: Building A Safer Health System. Washington, DC: National Academies Press; 2000. 8. Kowalczyk L. Safety list cuts surgery deaths. Boston Globe. January 15, 2009. http://www.boston .com/news/local/massachusetts/articles/2009/01 /15/safety_list_cuts_surgery_deaths. Accessed February 14, 2009. 9. Elpern EH, Covert B, Kleinpell R. Moral distress of staff nurses in a medical intensive care unit. Am J Crit Care. 2005;14(6):523-530. http://ajcc.aacnjournals.org /cgi/reprint/14/6/523. Accessed February 14, 2009. 10. Chen PW. When doctors and nurses can’t do the right thing. New York Times. February 6, 2009. http://www.nytimes.com/2009/02/06/health/05c hen.html?_r=1&em. Accessed February 14, 2009. 11. Levy P. What does it take? In: Running a Hospital [Internet blog]. January 15, 2009. http://running ahospital.blogspot.com/2009/01/what-does-it-take .html. Accessed February 14, 2009.
PATRICIA C. SEIFERT RN, MSN, CNOR, CRNFA, FAAN EDITOR-IN-CHIEF
Final Rule on Nondiscrimination Issued
T
he US Department of Health and Human Services (HHS) has issued a final rule that protects health care providers from discrimination by recipients of HHS funds for refusing to perform lawful health services or research to which they object, according to a December 18, 2008, news release from HHS. The final rule, which went into effect on January 18, 2009, • clarifies that nondiscrimination protections apply to institutional health care providers as well as individual employees who work for recipients of certain funds from HHS, • requires recipients of certain HHS funds to certify their compliance with the laws protecting provider conscience rights, and • designates the HHS Office for Civil Rights as the
entity to receive discrimination complaints. Officials from the HHS are responsible for working with state or local governments or entities that may have been in violation of discrimination statutes and encouraging voluntary compliance. Entities that do not comply may lose HHS funding or be required to return funds paid out in violation of the nondiscrimination provisions. The final rule can be accessed at http://edocket.access.gpo.gov /2008/E8-30134.htm. HHS issues final regulation to protect health care providers from discrimination [news release]. Washington, DC: US Department of Health and Human Services; December 18, 2008.
AORN JOURNAL •
655
Checklists and Safety Improvements PATRICIA C. SEIFERT, RN, MSN, CNOR, CRNFA, FAAN, EDITOR-IN-CHIEF
I
n a December 2007 article in The New Yorker magazine,1 Atul Gawande, MD, describes a checklist developed by Peter Pronovost, MD, PhD, in 2001. The checklist was introduced into a critical care unit to decrease the incidence of catheterrelated bloodstream infections, which are also a concern in surgical patients who require central line insertion. According to Dr Gawande, the steps in Dr Pronovost’s checklist included 1) hand washing with soap; 2) using chlorhexidine to cleanse the patient’s skin; 3) fully covering the patient with sterile drapes; 4) wearing a hat, mask, sterile gown and gloves; and 5) applying sterile dressings to the catheter insertion site. Dr Gawande describes the initial resistance by medical and nursing staff members to the use of this procedural tool. Clinicians’ objections included concerns that the use of the checklist would delay patient care, that it would not reduce medical error, and that it would annoy physicians and administrators. Dr Pronovost persisted, and in 2003, the checklist was tested in 103 intensive care units (ICUs). The study’s results, published in 2006,2 showed a dramatic reduction in the number of catheterrelated infections. Within three months, infections decreased from 2.7 infections to zero infections per 1,000 catheter days. Dr Pronovost’s findings demonstrated not only a reduction in central line infections but also that implementation of a specific and deliberate process would improve patient safety. It is significant that Dr Pronovost and his coauthors noted that “. . . a
© AORN, Inc, 2009
checklist was used to ensure adherence to infection control practices [and] providers were stopped (in nonemergency situations) if these practices were not being followed. . . .”2(p2726) These two considerations—use of a checklist and cessation of activity if the steps of the process are not enacted—have become cornerstones of Use of a checklist the safety movement.
SURGICAL SAFETY CHECKLISTS
and
cessation of activity if the steps of the
For perioperative patients, the introduction of process have not a standardized procedure employing a checkbeen followed have list to prevent wrong site, wrong procedure, become cornerstones and wrong person surgery was generated from of the safety a summit convened by the Joint Commission in movement. 2003.3 The resulting Universal Protocol established by the Joint Commission became part of its health care organization accreditation process in 2004.3,4 More recently, the World Health Organization (WHO) introduced the Surgical Safety Checklist as part of its Safe Surgery Saves Lives program5 to reduce surgical complications on a global scale. The checklist specifies actions in three phases of surgery: • before induction of anesthesia (ie, Sign In); • before the skin incision (ie, Time Out); and • before the patient leaves the OR (ie, Sign Out).5 In a prospective study performed in
APRIL 2009, VOL 89, NO 4 • AORN JOURNAL •
653
Editorial
APRIL 2009, VOL 89, NO 4
eight countries between October 2007 and September 2008, researchers using the WHO checklist demonstrated reductions in both the death rate (from 1.5% to 0.8%) and complications rate (from 11% to 7%).6 Although not all errors can be prevented, it is estimated that more than half of surgical complications are preventable.6,7 Given the substantial evidence demonstrated by Dr Gawande, Dr Pronovost, and others6 that checklists improve safety, why are there not fewer errors?
BARRIERS
TO
SAFE CARE
are ridiculed for wanting to adhere to a safety checklist and perform a time out or are told that “it’s not necessary because I know what I’m doing.” These barriers and other forms of resistance to following established procedures should not be tolerated. Individuals—physicians, nurses, or other personnel—cannot choose to be noncompliant and deviate from established and proven procedures that reduce error. All members of the team are important to patient care, and each member must be able to function in an environment that encourages compliance All members of the with practices that promote safe patient care. surgical team are
Some insights come from both media representatives and health care professionals. For example, writing on the INVOLVING ALL important to patient Boston Globe web site about MEMBERS OF THE TEAM an article by Haynes and Teamwork is a basic tenet care, and each member colleagues6 that discusses of safety. Perhaps what is the WHO checklist, Liz needed is a redefinition of must be able to Kowalczyk8 mentions OR staff what constitutes team memmembers’ concerns about bership. The importance of function in an wasting time with the checkadministrative support was list when there is pressure to addressed by Dr Gawande, environment that turn over an OR. In interviewHaynes et al, and also by Paul ing the study’s authors, Levy, president and chief encourages compliance Kowalczyk notes that they executive officer of Beth Israel “said it takes a strong commitDeaconess Medical Center in with practices that Boston, Massachusetts. On his ment by hospital leadership to blog of January 15, 2009, Levy adopt this type of change.”8 promote safe care. When there is greater pressure writes that when he chalto focus on turnover time lenged hospital administrarather than checklist time, tors about using the checklist, there is not only an increased “the response [was] silence.”11 risk for error but also greater potential for frusSilence is not an option. Active support by tration among staff members. health care facility leaders is critical to the sucFrustration on the part of caregivers can cessful implementation of a safety checklist. lead to moral distress—the inability to act in an Given their influence in creating and mainethical manner because of obstacles within a taining a culture of safety, health care execusituation.9 Pauline Chen, MD, writing in the tives are de facto members of the surgical New York Times,10 describes a nurse colleague team. Administrators may not be physically who felt conflicted because she was unable to present during a time out, but their support express her concerns about patient care without and a “no exceptions” commitment to combeing labeled unprofessional by supervisors or pleting a safety checklist certainly constitute “out of line” by physicians,10 and at the same fulfillment of team membership criteria. Patients are also team members. Perioperatime she felt, “If I don’t say anything . . . the tive nurses can play an important role by patient might suffer.”10 Perioperative nurses educating administrators and patients, as face barriers to doing the right thing when they
654 • AORN JOURNAL
Editorial
APRIL 2009, VOL 89, NO 4
well as recalcitrant surgical colleagues, about the positive results of using checklists. The benefits include not only better patient outcomes, but also fewer legal liabilities, greater staff satisfaction and reduced staff turnover, and positive financial returns. It seems improbable, but something as simple as a checklist can have profound effects. Editor’s note: The Universal Protocol is a trademark of the Joint Commission, Oakbrook Terrace, IL.
REFERENCES 1. Gawande A. The checklist. The New Yorker. December 10, 2007. http://www.newyorker.com /reporting/2007/12/10/071210fa_fact_gawande. Accessed February 14, 2009. 2. Pronovost P, Needham D, Berenholtz S, et al. An intervention to decrease catheter-related bloodstream infections in the ICU. New Engl J Med. 2006; 355(26):2725-2732. 3. Mulloy DF, Hughes RG. Wrong-site surgery: a preventable medical error. In: Hughes RG, ed. Patient Safety and Quality: An Evidence-Based Handbook for Nurses. Vol 2. [AHRQ Publication Number 08-0043]. Rockville, MD: Agency for Healthcare Research and Quality; 2008:2-381–2-395. http://www.ahrq.gov/qual/nurseshdbk. Accessed February 14, 2009. 4. Universal Protocol. The Joint Commission. http://www.jointcommission.org/PatientSafety /UniversalProtocol. Accessed February 14, 2009. 5. Surgical Safety Checklist. World Health Organi-
zation. http://www.who.int/patientsafety/safe surgery/tools_resources/SSSL_Checklist_finalJun08 .pdf. Accessed February 14, 2009. 6. Haynes AB, Weiser TG, Berry WR, et al; Safe Surgery Saves Lives Study Group. A surgical safety checklist to reduce morbidity and mortality in a global population. New Engl J Med. 2009;360(5):491499. Epub January 14, 2009. http://content.nejm.org /cgi/content/full/NEJMsa0810119. Accessed February 14, 2009. 7. Institute of Medicine. Kohn LT, Corrigan JM, Donaldson MS, eds. To Err Is Human: Building A Safer Health System. Washington, DC: National Academies Press; 2000. 8. Kowalczyk L. Safety list cuts surgery deaths. Boston Globe. January 15, 2009. http://www.boston .com/news/local/massachusetts/articles/2009/01 /15/safety_list_cuts_surgery_deaths. Accessed February 14, 2009. 9. Elpern EH, Covert B, Kleinpell R. Moral distress of staff nurses in a medical intensive care unit. Am J Crit Care. 2005;14(6):523-530. http://ajcc.aacnjournals.org /cgi/reprint/14/6/523. Accessed February 14, 2009. 10. Chen PW. When doctors and nurses can’t do the right thing. New York Times. February 6, 2009. http://www.nytimes.com/2009/02/06/health/05c hen.html?_r=1&em. Accessed February 14, 2009. 11. Levy P. What does it take? In: Running a Hospital [Internet blog]. January 15, 2009. http://running ahospital.blogspot.com/2009/01/what-does-it-take .html. Accessed February 14, 2009.
PATRICIA C. SEIFERT RN, MSN, CNOR, CRNFA, FAAN EDITOR-IN-CHIEF
Final Rule on Nondiscrimination Issued
T
he US Department of Health and Human Services (HHS) has issued a final rule that protects health care providers from discrimination by recipients of HHS funds for refusing to perform lawful health services or research to which they object, according to a December 18, 2008, news release from HHS. The final rule, which went into effect on January 18, 2009, • clarifies that nondiscrimination protections apply to institutional health care providers as well as individual employees who work for recipients of certain funds from HHS, • requires recipients of certain HHS funds to certify their compliance with the laws protecting provider conscience rights, and • designates the HHS Office for Civil Rights as the
entity to receive discrimination complaints. Officials from the HHS are responsible for working with state or local governments or entities that may have been in violation of discrimination statutes and encouraging voluntary compliance. Entities that do not comply may lose HHS funding or be required to return funds paid out in violation of the nondiscrimination provisions. The final rule can be accessed at http://edocket.access.gpo.gov /2008/E8-30134.htm. HHS issues final regulation to protect health care providers from discrimination [news release]. Washington, DC: US Department of Health and Human Services; December 18, 2008.
AORN JOURNAL •
655