CAMDEN, S.C.—Surgical team members shuffle in and out of the operating room preparing for the second procedure of the day at KershawHealth, a 120-bed hospital in a town of about 7,000 in north central South Carolina.
With a man on the operating table for a laparoscopic gallbladder removal, an anesthesiologist checks levels on a monitor. A nurse sets up bandages and other supplies on a tray. Dr. Edward Gill, the surgeon, takes a final look at markings designating the surgical area on the patient's stomach. Some make small talk about the risk of flooding because of heavy rains as Christmas approaches. “All right, let's get started,” Gill announces. It's 7:35 a.m.
But then everyone stops. No scalpel is lifted. All eyes turn to a poster labeled in jumbo print, “KershawHealth Safe Surgery Checklist,” on the wall at the foot of the surgical table.
The team goes over each item on the list aloud, and each member participates. The registered nurse confirms the patient's name and date of birth, that X-ray equipment is in the room, and that the man is allergic to a common pain medicine. The anesthesiologist states the type of drug being administered and that there are no current issues with the airway. The surgical technician, circulating nurse and others also weigh in.
Finally, Gill again confirms the type of surgery, says it should last about an hour, and notes that the patient has hypertension, a chronic health problem that could affect the procedure's outcome.
“Does anyone have anything to add? Speak up,” Gill says as he looks around the room. When no one speaks, the operation begins at 7:37 am. The process lasted just under two minutes.
The pause for the checklist is intended to help the team avoid terrible mistakes like operating on the wrong person or body part. It also facilitates communication among clinicians, who otherwise say surprisingly little to one another before, during or after a procedure. When used effectively, proponents say checklists improve efficiency in the OR, an area considered by some safety leaders to be among the most chaotic places in a hospital.
Surgical checklists, an approach drawn from commercial aviation and other high-risk industries, gained popularity when the World Health Organization promoted them in 2007 under the leadership of surgeon and author Dr. Atul Gawande. He further popularized them in an influential book, The Checklist Manifesto, published in 2009.
But they have yet to become widely or systematically adopted. As a result, there's not much data on their effectiveness, which in turn complicates the sales pitch to persuade organizations to invest the time and resources required to make them work.
South Carolina is now the testing ground for a much more focused approach. In 2013, the South Carolina Hospital Association, working with Gawande and the Harvard University School of Public Health, launched a structured initiative to get every hospital in the state to regularly use a pre-surgical safety checklist process.
The leaders of the project estimated that doing so could save 500 patient lives a year by averting medical mistakes. Harvard researchers gathered administrative data and data from the state's death registry to track mortality outcomes in places that have adopted checklists. Initial findings have been submitted for peer review and may be published this spring.
South Carolina was chosen for Harvard's project because of the state's previous investment in an all-payer administrative data set. In addition, the state launched a multiyear project with the Joint Commission in 2013 to improve the overall quality and safety of patient care.
Hospitals and health systems struggle to create the culture required to become high-reliability organizations, Joint Commission CEO Dr. Mark Chassin said in a recent interview, using a term that describes organizations that are engaged in complex and high-risk activities but still manage to avoid catastrophic events. “Healthcare can get to that state where the operation of the organization is so good that zero harm is a byproduct of the way they do their work.”
But checklists fail when they're tossed into an environment that doesn't fully support the effort or when the checklist approach isn't tailored to match the organization's needs and culture, Gawande said.
“It takes leadership support at the top and enthusiasts on the frontline,” he said. “You need both, because enthusiasm dies on the vine without a system behind you.”
Indeed, the South Carolina Hospital Association found that acceptance of the checklist process varied from hospital to hospital, but those that had the most success had committed to following all of the steps needed to become high-reliability organizations—they offered leadership support, financial resources and cultivated staff members who were dedicated to the enterprise. They also allowed staff to customize the process.
“One size does not fit all,” said Lorri Gibbons, vice president for quality improvement and patient safety at the association. To that end, the group brought in engineers with expertise in process improvement to visit every hospital, observe its procedures, and make recommendations to help each facility tailor the tool to meet its needs.