Are We Done Disrupting Patient Safety in Surgery?
Fact 1: It has been over ten years since the last disruption in surgical patient safety.
The last disruption was something that many people assumed was already happening. A 19 questions paper checklist that assures the basic stuff: that the team members introduce themselves, that it’s the right patient, the right procedure, the right limb. That everyone on the surgical team is aligned on the most critical details (1).
Here’s how it looks like:
Fact 2: The surgical checklist was shown to significantly reduce morbidity and mortality.
Believe it or not, this simple measure has been proven to reduce mortality by ~50% and complications by ~30%, in one of the most cited studies on surgical patient safety: ‘A Surgical Safety Checklist to Reduce Morbidity and Mortality in a Global Population’ (2).
Since 2009, the checklist has been implemented in hospitals worldwide. The process of going over the checklist in the operating room, just before the procedure starts, is called ‘Time out’.
The book ‘The Checklist Manifesto’ by the surgeon Dr. Atul Gawande provides a fascinating overview of the thought process that led to this research, and shows how Gawande’s team developed the checklist and applied it around the world.
The Checklist Manifesto is an eye opening book. It is also a New York Times, Wall Street Journal, USA Today, Entertainment Weekly, Washington Post, Los Angeles Times, Boston Globe, and San Francisco Chronicle bestseller.
But I hope this is not the best we can do about surgical safety.
Fact 3: The surgical quality status quo is education-focused.
The surgical checklist introduced a change to the surgical team’s workflow. This is very rare. The 2021 status quo is that quality and patient safety are still largely addressed through education.
Health quality organizations and societies concentrate their efforts on publishing instructional modules, presentations, online courses and training sessions for surgical teams.
Is an annual self-paced training on quality the best way to promote quality in surgery? The radical results of the safety checklist indicate that in order to achieve a real impact, best practices need to be embedded in the workflow.
Fact 4: Improving surgical quality is a team sport.
I encountered this tweet today about a new publication on the critical impact of team engagement on the efficacy of the surgical checklist. The author concludes that improving surgical quality requires humans and checklists to work together in partnership.
“To be effective, a checklist needs steadfast engagement by the team using it to improve safety”
This is a fundamental point. The checklist on its own is not enough. There are still missing components, and surgical team collaboration is one of them.
I am optimistic about the future of patient safety in surgery. Humanity has more tools to improve it than ever, and more importantly it has tools to improve it in a way that also reduces costs: higher quality doesn’t have to be more expensive. I believe we are not done disrupting in this space.
As 2022 approaches, here are my three prediction on the future of surgical quality and safety:
- The next disruption in surgical safety will be focused on team collaboration and team culture.
- Surgical patient safety improvement efforts are going to shift from educational/training to operational, and how to embed quality improvement in the day to day work without burdening with administrative work.
- Automation will be a critical enabler of patient safety, since it can help drive quality improvement without increasing administrative burden and costs.
(2) Haynes AB, Weiser TG, Berry WR, Lipsitz SR, Breizat AH, Dellinger EP, Herbosa T, Joseph S, Kibatala PL, Lapitan MC, Merry AF, Moorthy K, Reznick RK, Taylor B, Gawande AA; Safe Surgery Saves Lives Study Group. A surgical safety checklist to reduce morbidity and mortality in a global population. N Engl J Med. 2009 Jan 29;360(5):491–9. doi: 10.1056/NEJMsa0810119. Epub 2009 Jan 14. PMID: 19144931.