- Email: [email protected]
The Power of Checklists
PRESIDENT’S MESSAGE
The Power of Checklists MARTHA STRATTON, MSN, MHSA, RN, CNOR, NEA-BC, AORN PRESIDENT
T
he December 1994 issue of JAMA featured an article titled “Error in medicine,”1 in which author Lucian Leape, MD, postulated that an overwhelming number of medical errors were preventable. After publication of this article, he became widely recognized as a leader of the patient safety movement in health care.2 Approximately two years later, on November 29, 1999, the Institute of Medicine released To Err is Human: Building a Safer Health System,3 which explicated a comprehensive strategy to reduce medical errors. In March 2001, the Institute of Medicine issued another report, titled Crossing the Quality Chasm: A New Health System for the 21st Century,4 which concentrated on methods to reinvent the health care system to provide better-quality care. Since the publication of these two seminal reports, there has been an intense focus on patient safety, with a particular emphasis on patients undergoing surgical or other invasive procedures. In July 2003, the Joint Commission on the Accreditation of Healthcare Organizations (JCAHO, now The Joint Commission) published the Universal Protocol for Preventing Wrong Site, Wrong Procedure, and Wrong Person Surgery, which went into effect as a JCAHO standard on July 1, 2004.5 In this protocol were several provisions that were considered revolutionary at the time but have become a standard for surgical patient care. These included a preprocedure verification, the marking of the intended surgical site by the surgeon, and a pause (ie, time out) immediately before the beginning of the procedure to verify the correct patient, correct procedure, and correct site. I distinctly remember the resistance from nurses and surgeons to performing these tasks and the angst surrounding implementation of the Universal Protocol. It created a significant change in the flow and rhythm of procedures and was challenged as being unnecessary. It was not easy to persuade practitioners that this would protect
the patient. It was not until data from patient safety research began to appear in juried journals that health care professionals began adopting these recommendations. The Universal Protocol was but a precursor to the current patient safety checklists that encompass a preprocedure briefing, a time out before the start of the procedure, and a debrief at the end of the procedure.
THE ADOPTION AND USE OF CHECKLISTS On June 25, 2008, the World Health Organization (WHO) Safe Surgery Saves Lives initiative was formally launched and was led by Atul Gawande, MD, MPH, a surgeon and public health researcher with the Harvard School of Public Health.6 Under Dr Gawande’s leadership, the WHO Surgical Safety Checklist was created. At its introduction, this checklist received the endorsement of 200 nursing, surgery, anesthesia, and patient safety organizations, including AORN. The use of a surgical safety checklist is supported by The Joint Commission in relation to its Universal Protocol, and the WHO is cited as a reference associated with the standard.7 Some form of the WHO Surgical Safety Checklist has been widely adopted across the United States, and in today’s world of perioperative nursing, it would be almost unthinkable to begin a surgical procedure without performing all of the safety checks. Although there is strong evidence supporting the effectiveness of surgical checklists, there is still work to be done.8 In March 2016, The Joint Commission provided updated data to reflect the most frequently reported sentinel events through 2015, which showed that wrong-patient, wrong-site, or wrongprocedure surgery was the second most frequently reported event. The most frequently identified root cause of sentinel
http://dx.doi.org/10.1016/j.aorn.2016.04.013 ª AORN, Inc, 2016
www.aornjournal.org
AORN Journal j 549
Stratton
Additional Resources AORN has a wealth of resources to assist in implementing a patient safety program, including the following: Correct Site Surgery Tool Kit: https://www.aorn.org/ guidelines/clinical-resources/tool-kits/correct-site-surgery -tool-kit Creating a Practice Environment of Safety Tool Kit: https://www.aorn.org/guidelines/clinical-resources/tool -kits/creating-a-practice-environment-of-safety-tool-kit Guidelines for Perioperative Practice Position Statement on Preventing Wrong-Patient, WrongSite, Wrong-Procedure Events: https://www.aorn.org/ guidelines/clinical-resources/position-statements
events was human factors, and the second leading cause was leadership (eg, organizational planning).9 How do we diminish the effect of human factors such as inattention or distractions? How do we take the time for extra steps when there is urgency surrounding the start of a procedure? How do we make sure that we know we have the correct patient and are performing the correct procedure at the correct surgical site? How do leaders use planning to mitigate the risk to patients? Checklists are one proven way to reduce patient harm. There is a body of credible evidence to show that we can, and have, reduced adverse events through appropriate planning, education, and implementation of a surgical checklist.10-12 A 2012 research article in the Journal of American College of Surgeons stated that use of a comprehensive surgical safety checklist and implementation of a structured team training curriculum produced a statistically significant decrease in 30-day morbidity. Adoption of a comprehensive checklist is feasible with team training intervention and can produce measurable improvements in patient outcomes.13(p775-776)
Perioperative leaders need to ensure that safe surgery checklists are used effectively. This requires a team-based approach to implementation, consistent monitoring of compliance, systematic training and retraining, and active engagement of all staff members in patient safety processes.
NATIONAL TIME OUT DAY A critical part of the checklist is the time out pause immediately before the start of the procedure to validate that the correct procedure is being performed on the correct patient and that everyone knows the location of the surgical site. 550 j AORN Journal
June 2016, Vol. 103, No. 6
In 2004, AORN initiated a National Time Out Day to bring awareness to this critical element of patient safety. The Joint Commission, WHO, and Council on Surgical and Perioperative Safety have endorsed and supported National Time Out Day since it began.14 A publication from the American College of Surgeons in 2014 stated, National Time Out Day provides a timely opportunity for surgeons and their operating room (OR) teams to review the importance of conducting a safe, effective time out for every patient, every time. In addition, it encourages surgical team members to feel comfortable about speaking up for safe practices in the OR.15
As we go forward in our practice, it is reassuring to know that AORN provides us with the support and resources we need to safely care for our patients. National Time Out Day is June 8, and I encourage you to acknowledge and support this important component of patient safety on this day and every day that you practice in the perioperative setting.
CONCLUSION Perioperative nurses are especially attuned to the risks inherent in surgical processes and the responsibility we have to mitigate those hazards. Checklists provide an excellent device for clarifying inconsistencies or misunderstandings about the patient or the procedure. Pausing for a time out gives us that one pivotal moment to make sure the entire team is clear on the purpose and progress of the procedure. Keeping our patients safe is part of our enduring trust with our patients. It is our commitment and our honor as perioperative nurses to provide safe patient care.
Editor’s note: The Universal Protocol for Preventing Wrong Site, Wrong Procedure, Wrong Person Surgery is a registered trademark of The Joint Commission, Oakbrook Terrace, Ill.
References 1. Leape L. Error in medicine. JAMA. 1994;272(23):1851-1857. 2. Patient safety interview: Lucian Leape. World Health Organization. http://www.who.int/patientsafety/information_centre/interviews/ leape/en/. Published May 2007. Accessed April 20, 2016. 3. 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. 4. Institute of Medicine. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: National Academies Press; 2001. http://www.iom.edu/Reports/2001/Crossing-the -Quality-Chasm-A-New-Health-System-for-the-21st-Century.aspx. Accessed March 7, 2016.
www.aornjournal.org
June 2016, Vol. 103, No. 6 5. Universal Protocol. The Joint Commission. http://www .jointcommission.org/standards_information/up.aspx. Accessed March 7, 2016. 6. Launch of Safe Surgery Saves Lives - 25 June 2008. World Health Organization. http://www.who.int/patientsafety/safesurgery/ launch/en/. Published June 25, 2008. Accessed March 8, 2016. 7. Safe Surgery Checklist. The Joint Commission. http://www .jointcommission.org/safe_surgery_checklist/. Published July 24, 2012. Accessed March 8, 2016. 8. Treadwell JR, Lucas S. Preoperative checklists and anesthesia checklists. In: Making Health Care Safer II: An Updated Critical Analysis of the Evidence for Patient Safety Practices. Rockville, MD: Agency for Healthcare Research and Quality; 2013:122-139 (Evidence Reports/Technology Assessments, No. 211). 9. Quality and safety: sentinel event statistics updated, released through end of 2015. The Joint Commission. http://www.jointcommission .org/issues/article.aspx?Article¼1AF4aJcIzvBc%2bAMu%2fi5RwBBi JDoM0RWvmjtlIqwp6HM%3d. Published March 2, 2016. Accessed March 7, 2016. 10. 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. N Engl J Med. 2009;360(5): 491-499. 11. Weiser TG, Haynes AB, Dziekan G, Berry WR, Lipsitz SR, Gawande AA; Safe Surgery Saves Lives Investigators and Study Group. Effect of a
www.aornjournal.org
President’s Message
12.
13.
14.
15.
19-item surgical safety checklist during urgent operations in a global patient population. Ann Surg. 2010;251(5):976-980. de Vries EN, Prins HA, Crolla RM, et al; SURPASS Collaborative Group. Effect of a comprehensive surgical safety system on patient outcomes. N Engl J Med. 2010;363(20):1928-1937. Bliss LA, Ross-Richardson CB, Sanzari LJ, et al. Thirty-day outcomes support implementation of a surgical safety checklist. J Am Coll Surg. 2012;215(6):766-776. Dailey PA. Wondering about the “surgical pause” or “time-out?” California Society of Anesthesiologists. CSA Bulletin. http://www.csahq .org/pdf/bulletin/issue_2/wrongsite.pdf. Accessed March 8, 2016. National Time Out Day focuses on every patient, every time. American College of Surgeons. http://bulletin.facs.org/2014/06/national-time -out-day-focuses-on-every-patient-every-time. Published June 1, 2014. Accessed March 8, 2016.
Martha Stratton, MSN, MHSA, RN, CNOR, NEA-BC, is the AORN president and the vice president of Perioperative Services at Doctors Hospital of Augusta, GA. Ms Stratton has no declared affiliation that could be perceived as posing a potential conflict of interest in the publication of this article.
AORN Journal j 551
The Power of Checklists MARTHA STRATTON, MSN, MHSA, RN, CNOR, NEA-BC, AORN PRESIDENT
T
he December 1994 issue of JAMA featured an article titled “Error in medicine,”1 in which author Lucian Leape, MD, postulated that an overwhelming number of medical errors were preventable. After publication of this article, he became widely recognized as a leader of the patient safety movement in health care.2 Approximately two years later, on November 29, 1999, the Institute of Medicine released To Err is Human: Building a Safer Health System,3 which explicated a comprehensive strategy to reduce medical errors. In March 2001, the Institute of Medicine issued another report, titled Crossing the Quality Chasm: A New Health System for the 21st Century,4 which concentrated on methods to reinvent the health care system to provide better-quality care. Since the publication of these two seminal reports, there has been an intense focus on patient safety, with a particular emphasis on patients undergoing surgical or other invasive procedures. In July 2003, the Joint Commission on the Accreditation of Healthcare Organizations (JCAHO, now The Joint Commission) published the Universal Protocol for Preventing Wrong Site, Wrong Procedure, and Wrong Person Surgery, which went into effect as a JCAHO standard on July 1, 2004.5 In this protocol were several provisions that were considered revolutionary at the time but have become a standard for surgical patient care. These included a preprocedure verification, the marking of the intended surgical site by the surgeon, and a pause (ie, time out) immediately before the beginning of the procedure to verify the correct patient, correct procedure, and correct site. I distinctly remember the resistance from nurses and surgeons to performing these tasks and the angst surrounding implementation of the Universal Protocol. It created a significant change in the flow and rhythm of procedures and was challenged as being unnecessary. It was not easy to persuade practitioners that this would protect
the patient. It was not until data from patient safety research began to appear in juried journals that health care professionals began adopting these recommendations. The Universal Protocol was but a precursor to the current patient safety checklists that encompass a preprocedure briefing, a time out before the start of the procedure, and a debrief at the end of the procedure.
THE ADOPTION AND USE OF CHECKLISTS On June 25, 2008, the World Health Organization (WHO) Safe Surgery Saves Lives initiative was formally launched and was led by Atul Gawande, MD, MPH, a surgeon and public health researcher with the Harvard School of Public Health.6 Under Dr Gawande’s leadership, the WHO Surgical Safety Checklist was created. At its introduction, this checklist received the endorsement of 200 nursing, surgery, anesthesia, and patient safety organizations, including AORN. The use of a surgical safety checklist is supported by The Joint Commission in relation to its Universal Protocol, and the WHO is cited as a reference associated with the standard.7 Some form of the WHO Surgical Safety Checklist has been widely adopted across the United States, and in today’s world of perioperative nursing, it would be almost unthinkable to begin a surgical procedure without performing all of the safety checks. Although there is strong evidence supporting the effectiveness of surgical checklists, there is still work to be done.8 In March 2016, The Joint Commission provided updated data to reflect the most frequently reported sentinel events through 2015, which showed that wrong-patient, wrong-site, or wrongprocedure surgery was the second most frequently reported event. The most frequently identified root cause of sentinel
http://dx.doi.org/10.1016/j.aorn.2016.04.013 ª AORN, Inc, 2016
www.aornjournal.org
AORN Journal j 549
Stratton
Additional Resources AORN has a wealth of resources to assist in implementing a patient safety program, including the following: Correct Site Surgery Tool Kit: https://www.aorn.org/ guidelines/clinical-resources/tool-kits/correct-site-surgery -tool-kit Creating a Practice Environment of Safety Tool Kit: https://www.aorn.org/guidelines/clinical-resources/tool -kits/creating-a-practice-environment-of-safety-tool-kit Guidelines for Perioperative Practice Position Statement on Preventing Wrong-Patient, WrongSite, Wrong-Procedure Events: https://www.aorn.org/ guidelines/clinical-resources/position-statements
events was human factors, and the second leading cause was leadership (eg, organizational planning).9 How do we diminish the effect of human factors such as inattention or distractions? How do we take the time for extra steps when there is urgency surrounding the start of a procedure? How do we make sure that we know we have the correct patient and are performing the correct procedure at the correct surgical site? How do leaders use planning to mitigate the risk to patients? Checklists are one proven way to reduce patient harm. There is a body of credible evidence to show that we can, and have, reduced adverse events through appropriate planning, education, and implementation of a surgical checklist.10-12 A 2012 research article in the Journal of American College of Surgeons stated that use of a comprehensive surgical safety checklist and implementation of a structured team training curriculum produced a statistically significant decrease in 30-day morbidity. Adoption of a comprehensive checklist is feasible with team training intervention and can produce measurable improvements in patient outcomes.13(p775-776)
Perioperative leaders need to ensure that safe surgery checklists are used effectively. This requires a team-based approach to implementation, consistent monitoring of compliance, systematic training and retraining, and active engagement of all staff members in patient safety processes.
NATIONAL TIME OUT DAY A critical part of the checklist is the time out pause immediately before the start of the procedure to validate that the correct procedure is being performed on the correct patient and that everyone knows the location of the surgical site. 550 j AORN Journal
June 2016, Vol. 103, No. 6
In 2004, AORN initiated a National Time Out Day to bring awareness to this critical element of patient safety. The Joint Commission, WHO, and Council on Surgical and Perioperative Safety have endorsed and supported National Time Out Day since it began.14 A publication from the American College of Surgeons in 2014 stated, National Time Out Day provides a timely opportunity for surgeons and their operating room (OR) teams to review the importance of conducting a safe, effective time out for every patient, every time. In addition, it encourages surgical team members to feel comfortable about speaking up for safe practices in the OR.15
As we go forward in our practice, it is reassuring to know that AORN provides us with the support and resources we need to safely care for our patients. National Time Out Day is June 8, and I encourage you to acknowledge and support this important component of patient safety on this day and every day that you practice in the perioperative setting.
CONCLUSION Perioperative nurses are especially attuned to the risks inherent in surgical processes and the responsibility we have to mitigate those hazards. Checklists provide an excellent device for clarifying inconsistencies or misunderstandings about the patient or the procedure. Pausing for a time out gives us that one pivotal moment to make sure the entire team is clear on the purpose and progress of the procedure. Keeping our patients safe is part of our enduring trust with our patients. It is our commitment and our honor as perioperative nurses to provide safe patient care.
Editor’s note: The Universal Protocol for Preventing Wrong Site, Wrong Procedure, Wrong Person Surgery is a registered trademark of The Joint Commission, Oakbrook Terrace, Ill.
References 1. Leape L. Error in medicine. JAMA. 1994;272(23):1851-1857. 2. Patient safety interview: Lucian Leape. World Health Organization. http://www.who.int/patientsafety/information_centre/interviews/ leape/en/. Published May 2007. Accessed April 20, 2016. 3. 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. 4. Institute of Medicine. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: National Academies Press; 2001. http://www.iom.edu/Reports/2001/Crossing-the -Quality-Chasm-A-New-Health-System-for-the-21st-Century.aspx. Accessed March 7, 2016.
www.aornjournal.org
June 2016, Vol. 103, No. 6 5. Universal Protocol. The Joint Commission. http://www .jointcommission.org/standards_information/up.aspx. Accessed March 7, 2016. 6. Launch of Safe Surgery Saves Lives - 25 June 2008. World Health Organization. http://www.who.int/patientsafety/safesurgery/ launch/en/. Published June 25, 2008. Accessed March 8, 2016. 7. Safe Surgery Checklist. The Joint Commission. http://www .jointcommission.org/safe_surgery_checklist/. Published July 24, 2012. Accessed March 8, 2016. 8. Treadwell JR, Lucas S. Preoperative checklists and anesthesia checklists. In: Making Health Care Safer II: An Updated Critical Analysis of the Evidence for Patient Safety Practices. Rockville, MD: Agency for Healthcare Research and Quality; 2013:122-139 (Evidence Reports/Technology Assessments, No. 211). 9. Quality and safety: sentinel event statistics updated, released through end of 2015. The Joint Commission. http://www.jointcommission .org/issues/article.aspx?Article¼1AF4aJcIzvBc%2bAMu%2fi5RwBBi JDoM0RWvmjtlIqwp6HM%3d. Published March 2, 2016. Accessed March 7, 2016. 10. 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. N Engl J Med. 2009;360(5): 491-499. 11. Weiser TG, Haynes AB, Dziekan G, Berry WR, Lipsitz SR, Gawande AA; Safe Surgery Saves Lives Investigators and Study Group. Effect of a
www.aornjournal.org
President’s Message
12.
13.
14.
15.
19-item surgical safety checklist during urgent operations in a global patient population. Ann Surg. 2010;251(5):976-980. de Vries EN, Prins HA, Crolla RM, et al; SURPASS Collaborative Group. Effect of a comprehensive surgical safety system on patient outcomes. N Engl J Med. 2010;363(20):1928-1937. Bliss LA, Ross-Richardson CB, Sanzari LJ, et al. Thirty-day outcomes support implementation of a surgical safety checklist. J Am Coll Surg. 2012;215(6):766-776. Dailey PA. Wondering about the “surgical pause” or “time-out?” California Society of Anesthesiologists. CSA Bulletin. http://www.csahq .org/pdf/bulletin/issue_2/wrongsite.pdf. Accessed March 8, 2016. National Time Out Day focuses on every patient, every time. American College of Surgeons. http://bulletin.facs.org/2014/06/national-time -out-day-focuses-on-every-patient-every-time. Published June 1, 2014. Accessed March 8, 2016.
Martha Stratton, MSN, MHSA, RN, CNOR, NEA-BC, is the AORN president and the vice president of Perioperative Services at Doctors Hospital of Augusta, GA. Ms Stratton has no declared affiliation that could be perceived as posing a potential conflict of interest in the publication of this article.
AORN Journal j 551