CHECKING IN ON THE CHECKLIST Uptake, Impact, and Opportunities for the Next Decade COVER PHOTO: AHMED JALLANZO PREFACE 1 ACKNOWLEDGMENTS 2 EXECUTIVE SUMMARY 4 CHAPTER 1: A SIMPLE, EVIDENCE-BASED TOOL 6 TESTING THE CHECKLIST . 12 CHAPTER 2: THE ENTREPRENEURIAL PHASE 14 LESSONS LEARNED FROM EARLY ADOPTERS . 17. CHAPTER 3: THE CHECKLIST FOOTPRINT AT TEN YEARS 20 UNFINISHED BUSINESS: IMPLEMENTATION IN LMICS . 22 CHAPTER 4: IMPACT OF THE CHECKLIST 24 BEYOND MORTALITY AND MORBIDITY . .26 . CHAPTER 5: OPPORTUNITIES IN THE SECOND DECADE 28 CONTEXT AS AN INESCAPABLE DETERMINANT . 30 STRATEGIES TO GET TO SCALE AND SUSTAINED USE . 32. TOOLS FOR CHECKLIST IMPLEMENTATION AND USE . 34 . CONCLUSION: GETTING TO SCALE, SUSTAINING SAFER SURGICAL PRACTICES 36 ENDNOTES 38 PREFACE The very fact that surgery exists—that we to see how rapidly and enthusiastically it has can safely open people’s bodies, remove and been adopted. A pooled analysis of international rearrange the parts, close the bodies back up studies found that the Checklist is being used again, and turn out to have made people in 75% of operations globally. Multiple, large- better—is an astonishment. scale evaluations have confirmed substantial reductions in surgical complications and deaths Nonetheless, over the last century, the art that when implemented effectively. How? Leaders became a science has become a mass enterprise point to the way that use of the Checklist breaks delivering more than 300 million operations down operating room hierarchies, improves a year worldwide. Surgery has become an communication and compliance with best essential part of enabling human beings to live safety practices, and ultimately helps surgical long and healthy lives. It can address everything teams work together to provide safer care for from obstetric emergencies (cesarean sections their patients. are the most common operation on the planet) and traumatic injuries to congenital conditions The report also highlights, however, how and cataracts. And that fact is a marvel of challenging adoption of the Checklist remains, knowledge, training, logistics, and coordination especially in low- and middle-income countries, in the face of enormous complexity. where uptake remains slow and sporadic. Buy-in, adaptation, and support for effective In 2008 emerged one of the most significant Checklist implementation by individuals innovations for making safe, reliable surgical and surgical teams, health facilities, and care more possible at global scale. It wasn’t governments are proving to be key elements for a drug or device or new high-tech gadget. reaping the benefits of the Checklist whether in It was a checklist—the WHO (World Health South Carolina or southern India. Organization) Surgical Safety Checklist—a two-minute, single-page protocol with 19 items There is no single remedy to ensure safe surgery for reducing preventable human errors by for all. This report amply testifies to the challenges improving communication and teamwork in still faced by surgical teams worldwide in the operating room. I was lucky enough to have ensuring the safety of the care they are providing directed the WHO program that developed the to patients. The Checklist is only successful Checklist and oversaw the study in 8 hospitals when the teams using it are committed to around the world that found that its use could the teamwork, discipline, and humility that it cut death rates nearly in half. But surgical teams requires. Over the coming decade, as access to and hospitals across the world were the ones surgical care is increasingly recognized as a vital who put it into action. component of health care, advancement and adoption of powerful, simple, and cost-effective Reading the series of publications undertaken tools like the Checklist will be essential for by Lifebox and Ariadne Labs after a decade since ensuring that every human being can count on the introduction of the Checklist, I am stunned getting the right care everywhere, every time. –Atul Gawande Preface | 1 ACKNOWLEDGMENTS Checking In On the Checklist was researched Checking In On the Checklist is part of a joint and written by Marine Buissonniere. project of Lifebox and Ariadne Labs, both champions of the WHO Surgical Safety Checklist. Editorial support was provided by It is a report written by and for front-line users Luca Koritsanszky, Kris Torgeson, Deborah of the Surgical Safety Checklist from around the O’Neil, Yves Sonnay, Tom Weiser, Alex Haynes, world who are interested in sharing and learning George Molina, and Evan Benjamin. from each other’s implementation experiences. This is not a WHO report; rather, it reflects the The report was designed by Courtney Staples. learnings, insights, and experiences of frontline providers who have used a variety of strategies to Checking In On the Checklist is built on the implement this tool in their facilities. work of many individuals from around the world and we thank them for their continued Lifebox is a non-profit organization working to commitment to surgical and anesthesia safety. improve the safety of surgery and anesthesia in They include: low- and middle-income countries. Lifebox was founded by the Association of Anaesthetists of » The many members of the World Health Great Britain & Ireland, Brigham and Women’s Organization (WHO) Safe Surgery Program Hospital, the Harvard T.H. Chan School of Public whose consultation yielded the first Health, and the World Federation of Societies of Surgical Safety Checklist (www.who.int/ Anaesthesiologists in 2011. patientsafety/safesurgery/checklist/en); Ariadne Labs is a health systems innovation » The principal investigators of the original center at Brigham and Women’s Hospital and pilot study that revealed the Checklist’s the Harvard T.H. Chan School of Public Health. efficacy across low-, middle-, and high- Founded in 2012, Ariadne Labs is home to the income settings (Haynes et al., 2009); Safe Surgery Program. » Over 40 individuals interviewed who shared their firsthand experience with Lifebox and Ariadne Labs acknowledge the implementing the Checklist. important ongoing discussions about effective implementation of the Surgical Safety Checklist, and are committed to furthering Checklist research and effective implementation. 2 | Checking In On the Checklist The following individuals were amongst Alan Merry those interviewed for this report, but are not Specialist in anaesthesia and chronic pain responsible for its content or conclusions: management Auckland City Hospital, Auckland. Professor of anaesthesiology and deputy Ruslan Baltaga dean, faculty of medical and health sciences, Associate professor and chair of Anaesthesiology University of Auckland. Lifebox Foundation Reanimatology, Nicolae Testemitanu trustee, New Zealand International Hospital Medpark. Vice-president, Society of Anaesthesiology Reanimatology of the Ruth Tighe Republic of Moldova, Moldova Consultant, anaesthesia and intensive care medicine, Ashford, Kent, UK; past Lifebox Abebe Bekele anaesthesia fellow to the Kilimanjaro Christian Professor of surgery, general and thoracic Medical Center in Moshi, Tanzania, responsible for surgeon, and dean of the University of Global implementation of the Checklist, United Kingdom Health Equity, Rwanda Tihitena Negussie William Berry Assistant professor of surgery and consultant Senior advisor to the executive director and general & pediatrics surgeon, School of co-founder, Ariadne Labs, Boston, United States Medicine, Addis Ababa University, Ethiopia Nina Capo-Chichi Isabeau Walker WHO Checklist representative in Francophone Consultant pediatric anaesthetist, Great Ormond West Africa, Benin Street Hospital, NHS Foundation. Trustee, Association of Anaesthetists of Great Britain and Jigeeshu Divatia Ireland Foundation, Lifebox Foundation trustee, Professor and head, Department of Anaesthesia, United Kingdom Critical Care & Pain, Tata Memorial Hospital in Mumbai, India. Editor-in-chief, Indian Journal Thomas Weiser of Anaesthesia, and past president, Indian Associate professor of surgery at Stanford Society of Critical Care Medicine, India University Medical Center, practicing general, emergency, and trauma surgery and surgical Sujarit Giri intensive care. Visiting professor at the Anesthesiologist, Community Health Centre in University of Edinburgh, and clinical advisor to Sivasagar District of Assam, India Lifebox, United States Sandra Izquierdo Michelle White Anesthesiologist and honorary member of Pediatric anesthesiologist, Great Ormond Street Guatemalan Society of Anesthesia, Guatemala Hospital, London, UK; Centre for Global Health and Partnerships, King’s College London, UK; Leonard Kabongo and medical capacity building consultant, Mercy Chief medical officer, Ministry of Health and Ships, United Kingdom Social Services, Namibia Iain Wilson Mela Lapitan Consultant anaesthetist, Lifebox emeritus board Professor, Institute of Clinical Epidemiology member, United Kingdom (National Institutes of Health) and Department of Surgery at the University of the Philippines, Manilla, Philippines Acknowledgments | 3 EXECUTIVE SUMMARY In 2009, a landmark article published in The New England Journal of Medicine introduced RECOMMENDATIONS the World Health Organization’s Surgical Safety In Checking In On the Checklist, we see that Checklist and launched a new global movement implementation of this seemingly simple tool in surgical safety. is anything but a simple exercise. Rather, it’s a complex multidimensional process based on The Checklist—a 19-item list of prompts