1RCSI medical student
Royal College of Surgeons in Ireland Student Medical Journal 2011;4(1):67-69.
In March 2008, an eight-year-old boy in Our Lady’s Hospital for Sick Children in Crumlin had his healthy left kidney surgically removed. A series of mistakes resulted in the removal of the healthy kidney from the boy, and he left the operating theatre with only his diseased right kidney, functioning at 9% of normal. Prior to the surgery, his parents sensed that there was some confusion as to which kidney would be removed and voiced their concerns to several staff members.1 Despite this, the boy became another surgical error statistic, one that could have been avoided with the correct use of a surgical safety checklist.
Medical errors – causes and solutions
An integral part of human nature is that despite our greatest efforts, we all make mistakes. However, mistakes happen for different reasons, including forgetfulness, haste, disorganisation, intimidation and ‘groupthink’.2 Psychologist Irving Janis’ theory of groupthink explains how groups can prioritise cohesion among group members over individual critical thinking. As a result, groups can agree on subpar ideas that are potentially detrimental.3 Similarly, the Swiss Cheese Model of Error exemplifies how a series of mistakes at different logistical levels can combine to create a serious yet avoidable situation.4 In January 2007, in an effort to address the safety of surgical care, the World Alliance for Patient Safety initiated work on the World Health Organisation’s (WHO) Safe Surgery Checklist.5 The surgical safety checklist was created to safeguard against specific errors during all stages of surgery. When implemented correctly, it can significantly reduce cumulative oversights that lead to surgical error and considerably increase patient safety.6 Medical errors are estimated to seriously harm approximately one in ten hospitalised patients in the United States.7 A study done by the UK National Patient Safety Agency estimated that approximately 35,000 medical errors occur annually in Irish hospitals.7 In addition to mortality and morbidity, the financial cost of medical errors can also be devastating. Ireland spent approximately €74 million settling claims against health agencies between 2003 and 2008.8 While it is not feasible to eliminate human error entirely, Haynes et al. conducted a study that found that surgical deaths were reduced by approximately one-half and surgical complications were reduced by more than one-third when the surgical safety checklist was implemented.6,9 Thus, it seems worthwhile to implement simple yet effective strategies such as the surgical safety checklist to reduce error and undue surgical sequelae.6,9 Dr Atul Gawande, Director of the WHO’s Global Challenge for Safer Surgical Care, spearheaded the development of the surgical safety checklist that is being implemented globally to reduce surgical errors and standardise surgical safety.10 The checklist is a concise, single-page list divided into three phases: before anaesthesia; before the first incision; and before the patient is transferred to the surgical recovery room. Only once each task has been completed can the next item on the list be addressed (Figure 1).
The surgical safety checklist in Ireland
In operating theatres in Ireland, the head theatre sister is in charge of the checklist. The term ‘surgical time-out’ is used, referring to the time designated to completing the checklist in theatre. During the first phase of the checklist, the patient participates in the confirmation of their surgical site and has it marked before any anaesthesia is administered.
During the second phase, the surgeon and surgical staff confirm the correct patient, procedure and surgical site. During the third phase, when the surgery is complete and the patient is about to leave the theatre, there is a recapitulation of the procedure, a count of surgical instruments and a record of any errors made. The checklist consists of basic tasks arranged in a logical sequence and involves the patient and all members of the surgical multidisciplinary team. As a result, no single person is responsible for the verification procedure. Rather, several medical staff members have specific tasks allocated to them at different times, and they must confirm that their task was completed in front of other team members so that it may be ticked off the checklist.
Intuitively, distributing responsibility and increasing transparency reduces the possibility for error. By having more people involved in the safety protocol, there are more people designated to catch mistakes. Also, by structuring and standardising procedures, the potential for groupthink and errors attributable to hierarchical intimidation are decreased. The checklist is a basic outline and is intended to be tailored to each specific procedure for optimal efficacy. The correct use of the surgical safety checklist has demonstrably decreased patient morbidity and mortality dramatically, and is in the process of being implemented globally. Moreover, Gawande et al. have estimated that between $15 and $25 billion USD per year would be saved if the WHO surgical safety checklist were implemented in operating theatres across the United States.11 The UK, Canada, Ireland, Jordan and the Philippines have already integrated the surgical safety checklist into their nationwide operating theatres protocol.12,13 Currently, Ireland is reforming healthcare policies to increase accountability and public trust in the hope of changing societal attitudes towards healthcare. One goal is to increase public interest in the healthcare system, with an emphasis on public feedback and responsibility. Increasing the collection and availability of information about mortality rates, healthcare-related adverse events, hospital ratings, complaints and consequent actions would help to increase transparency and has been proposed as a future improvement.7,14 The Health Service Executive (HSE) has endorsed this movement by implementing the Transformation Programme between 2007 and 2010, the main goal of which is to advance services and to maintain new standards within the healthcare field so as to enable the Irish population to live healthier lives. “Success depends on all of us being open and willing to change, not just those directly or immediately involved”.15
The surgical safety checklist is being implemented across Ireland with varying adherence and criticism. To investigate the use of surgical checklists at Beaumont Hospital, Professor Arnold Hill, Chairman of Surgery at the Royal College of Surgeons in Ireland and Beaumont Hospital, and Mr Patrick J Broe, Vice President of the RCSI Council and Consultant Surgeon at Beaumont Hospital, were contacted by personal correspondence.16,17 Professor Hill and Mr Broe are both proponents of the surgical safety checklist, and agree that it is effective and valuable as long as there is strong leadership behind it and willingness from all team members to participate. From their experience, they note that the checklist engages the entire surgical team and allocates a specific time point to ensure that all team members introduce themselves. This seemingly insignificant component is particularly relevant in larger hospitals, where the staff members often do not know one another at the time of surgery. Even in smaller hospitals, such introductions help to reaffirm each member’s role and responsibility. This small step can encourage junior team members to speak up if they have cause for concern and can potentially be the difference between a successful surgery and a harmful procedure. Each person is also reminded that they have a clear responsibility to the patient’s safety, thereby diminishing the incidence of groupthink.
So long as the checklist is continually reassessed and updated, Professor Hill and Mr Broe both predict that it will continue to be an integral part of surgical safety and significantly contribute to better patient outcomes. The eight-year-old boy from Our Lady’s Hospital for Sick Children survived the operation but serves as a reminder of the impact of cumulative errors and the life-saving efficacy of a surgical safety checklist. The checklist has enormous potential for improving surgical morbidity and mortality well into the future.18
- Donnellan E. Mother asked for check before child’s wrong kidney removed. [homepage on the internet]. The Irish Times, May 28, 2010. Cited September 1, 2010. Available from: http://www.irishtimes.com/newspaper/frontpage/2010/0528/12242713 00512.html.
- Raven BH. Groupthink, Bay of Pigs, and Watergate reconsidered. Organ Behav Hum Decis Process. 1998;73(2/3):352-61.
- Mccauley C. Group dynamics in Janis’s theory of groupthink: backward and forward. Organ Behav Hum Decis Process. 1998;73(2/3):142-62.
- Reason J. Human error: models and management. BMJ. 2000;320:768.
- World Alliance for Patient Safety. WHO surgical safety checklist and implementation manual [homepage on the internet], 2008. Cited September 1, 2010. Available from: http://www.who.int/patientsafety/safesurgery/ss_checklist/en/index.html.
- World Health Organisation. New scientific evidence supports WHO findings: a surgical safety checklist could save hundreds of thousands of lives [homepage on the internet], 2010. Cited September 1, 2010. Available from: http://www.who.int/patientsafety/safesurgery/checklist_saves_lives/en/.
- Hunter N. Getting serious about medical error [homepage on the internet], April 23, 2008. Cited October 20, 2010. Available from: http://www.irishhealth.com/article.html?id=13454&ss=surgical%20error.
- Hunter N. State’s €74m health errors pay-out [homepage on the internet], October 5, 2009. Cited October 20, 2010. Available from: University of California website: http://www.irishhealth.com/article.html?id=16216&ss=surgical%20error.
- Haynes AB, Weiser TG, Berry WR. A surgical safety checklist to reduce morbidity and mortality in a global population. New Engl J Med. 2009;360:491-9.
- World Health Organisation. Atul Gawande [homepage on the internet], 2010. Cited October 20, 2010. Available from: http://www.who.int/patientsafety/about/atul_gawande/en/.
- Semel ME, Resch S, Haynes AB, Funk LM, Bader A, Berry WR et al. Adopting a surgical safety checklist could save money and improve the quality of care in US hospitals. Health Aff (Millwood). 2010;29(9):1593-9.
- World Health Organisation. The Second Global Patient Safety Challenge: Safe Surgery Saves Lives. In: World Alliance for Patient Safety, 2010.
- World Health Organisation. Surgical Safety Web Map [homepage on the internet], 2006. Cited December 23, 2010. Available from: http://maps.cga.harvard.edu:8080/Hospital/.
- O’Malley R. Complete transparency is only way to rebuild trust [homepage on the Internet], March 11, 2010. Cited November 1, 2010. Available from:http://www.independent.ie/opinion/analysis/ rebecca-omalley-complete-transparency-is-only-way-to-rebuild -trust-2095042.html.
- Health Service Executive. Transformation Programme 2007-2010. In: Health Service Executive, 2008.
- Hill A. Interviewed by Weiglein G, October 26, 2010.
- Broe P. Interviewed by Weiglein G, October 30, 2010.
- Donnellan E. Doctors cleared of misconduct in kidney mix-up case [homepage on the internet]. The Irish Times, September 4, 2010. Cited November 6, 2010. Available from: http://www.irishtimes .com/newspaper/ ireland/2010/0904/1224278203643.html.
- World Health Organisation. Safe Surgery Saves Lives: The Second Global Patient Safety Challenge [homepage on the internet], 2009. Cited December 23, 2010. Available from: http://www.who.int/patientsafety/safesurgery/en/index.html.