Checklist book a hit for Gainesville medical community

A new book by a general surgeon at Harvard is making its mark in the medical world.


Published: Sunday, January 31, 2010 at 2:48 p.m.
Last Modified: Sunday, January 31, 2010 at 2:48 p.m.

Dr. Atul Guwande, in “The Checklist Manifesto: How to Get Things Right,” spells out the vast complexities of modern-day medicine.

Facts

Check this out

According to Dr. Atul Gawande and the World Health Organization:
• Americans today undergo an average of seven operations in their lifetime.
• Surgeons perform more than 50 million operations annually.
• There are 150,000 deaths following surgery every year.
• Estimates for complication rates after surgery range from 3-17 percent.
• Research shows that at least half of the deaths and major complications are avoidable.

Shands uses checklists for:
• Surgery
• Interventional radiology
• Hospital discharge
• Stroke intervention
• Emergency department transfer
• Food refrigeration

Shands' surgical checklist
Covers such questions as:

• Has patient given consent for surgery, anesthesia?
• Is the procedural site marked?
• Have any allergies been identified?
• Is the patient in the right position?
• Is blood type matched and blood on hand if needed?
• Are the proper instruments on hand?
• Are relevant images displayed?
Before beginning:
• Team members introduce themselves.
• Each team member has a chance to cover their plan, express any concerns.
• Nurse checks off listed steps as they are completed.
After surgery:
• Attending anesthesiologist and surgeon must sign the completed checklist.

Tips for patients:
• Be active in your own health care and participate in the process.
• Feel empowered to ask “where is the checklist?” and be sure that everything is being done right.
• Understand that if you are asked the same questions by a series of people, there is a reason for that.
• Be aware that the health care team is doing this for a purpose.
• Respond to questions such as “what do you do for pain?” or “how often do you drink alcohol?” honestly, even if they make you uncomfortable.
• Ask questions of your own, such as “Will I be given an antibiotic before surgery and what is it?”
— Dr. Kayser Enneking, UF College of Medicine and Shands UF

He says medicine has become the art of managing extreme complexity. Health care professionals have at their disposal about 6,000 drugs and 4,000 medical and surgical procedures. It is a lot to get right.

His simple solution to getting things right is a checklist. And safety officers at Gainesville hospitals give the concept an enthusiastic thumbs up.

Checklists are in use both within the Shands hospital system and at North Florida Regional Medical Center.

Although the patient might not be aware they are in use, these checklists act as a sort of mental safety net. They catch flaws of memory and attention and thoroughness. They are designed to make a hospital stay safer.

And since Americans today undergo an average of seven operations in their lifetime and surgeons perform more than 50 million operations each year, that's important.

How important? Gawande and a team of researchers introduced a two-minute checklist in the operating rooms of eight hospitals in 2008.

The results were startling. Without adding a single piece of equipment or spending an extra dollar, all eight hospitals saw the rate of major postsurgical complications drop by 36 percent in the six months after the checklist was introduced; deaths fell by 47 percent.

“We got massively better results,” Gawande said. The checklist caught basic mistakes. It fostered good teamwork. And most importantly, it saved patients' lives.

“Our great struggle in medicine these days is not just with ignorance and uncertainty,” Gawande says. “It's also with complexity: how much you have to make sure you have in your head and think about. There are a thousand ways things can go wrong.”

Checklists, he says, vastly improve the odds of everything going right.

Debra Schollenberger is director of quality management and the patient safety officer at North Florida Regional Medical Center. Dr. Kayser Enneking chairs the quality committee at Shands at the University of Florida. She also heads the department of anesthesiology in the College of Medicine. Both women keep a copy of “The Checklist Manifesto” close at hand.

Schollenberger said that HCA, parent company of North Florida Regional Medical Center, began looking at ways to improve patient safety in 2000. The Gainesville hospital has been using a checklist system it calls the patient “boarding pass” for several years.

Shands UF also has embraced the idea of checklists, where they've been in use in many areas of the hospital for five years.

As Enneking says, “We all have mental checklists, but the beauty of the checklist (in the operating room) is that it stimulates conversation and communication among all the members of the surgical team, and the patient as well.

“When you work with somebody different every day, you need a formal way to communicate ‘this is how we do it,'” she said.

The ‘boarding pass'

Here's how Schollenberger explains the “boarding pass” concept at North Florida.

Before an operation can begin, the surgical team wants to ensure it has the correct patient, correct procedure and correct site.

The boarding pass is completed by each group along the patient's travels to the operating room. Patient verification begins when the procedure is scheduled, and again when the patient arrives at the hospital. In the pre-surgery holding area, all of the steps on the checklist are gone over again.

The surgeon does the site marking, and when the patient goes into the OR, there are a couple of timeouts, one with the anesthesiologist and a second with all of the members of the surgical team, to make sure everything is in place before the procedure begins.

Anyone on the team can lead the timeout, but typically it is the circulating nurse who does it. All of the questions are asked, and everyone must be in agreement before the first incision is made.

A changing culture

Enneking says the checklist system in place at Shands UF and the new Shands Cancer Hospital has changed the culture of the operating room.

Medicine has gone from the surgeon being captain of the ship, while everyone else follows in his or her wake, to being a team in the OR, she explains. The checklist has helped in that change of culture.

“We have redone the form about 18,000 times, and it gets a little bit better each time,” she said. “But it is the communication it sets up that is the beauty of the checklist.”

Even surgeons who have said, “I've done it this way for 30 years, why do I have to change?” will occasionally have a problem in the OR. And then they get onboard with the checklist concept.

Post-surgery, the completed checklist must be signed by the attending anesthesiologist and the attending surgeon.

The reason for a checklist is not to punish an error, Enneking said, but an acknowledgment that the world of medicine has become extremely complex.

“There are so many pieces that you have to put together to make it come off like a symphony,” she said.

It's more than just a checklist; it's the communication and teamwork that a checklist brings that's important, Enneking explained. All team members know they are accountable for their part in the procedure.

“You have to recognize that the focus of care has gone from being physician-driven to patient-driven,” she said. “As physicians, we always want to do the right thing, but now we must recognize that it is a team sport.”

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