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Hospital Checklists Reduce Surgical Complications, Deaths: Study

By Jenifer Goodwin
HealthDay Reporter

WEDNESDAY, Nov. 10 (HealthDay News) -- Hospitals that used checklists to prevent errors involving surgical patients dramatically reduced both complications and in-hospital deaths, a new study finds.

Between 2007 and 2009, six hospitals in the Netherlands implemented a series of 11 checklists that covered every aspect of surgical care from the moment the patient arrived at the hospital until discharge.

The checklists included about 100 items, covering pre-operative care, the operating room itself, recovery or intensive care and post-operative care. Items to be checked off included everything from making sure blood was available during surgery, double-checking that surgeons were operating on the correct site, and making sure the staff in the recovery ward or intensive care was clear on how to take care of the patient after surgery, including proper medications and when a patient should be allowed to eat again.

A comparison of about 7,600 patients -- half of whom underwent surgery before the checklists were being used and half who had surgery after implementation of the checklists -- found that checklists reduced complications by one-third. In-hospital deaths were cut in half.

"A comprehensive checklist for surgical patients that covers the entire surgical tract from admission to discharge was able to decrease mortality by half and morbidity by one-third," said study senior author Dr. Marja Boermeester, an associate professor and gastrointestinal surgeon at the Academic Medical Center in Amsterdam.

The study is published in the Nov. 11 issue of the New England Journal of Medicine.

Surgical errors remain a major concern in U.S. hospitals. A study published in October in the Archives of Surgery found that serious, devastating errors, such as operating on the wrong patient or the wrong body site, can and do occur. Many of the mistakes cited in that report occurred due to simple errors in judgment or because surgical teams had failed to perform standard pre-operation checks.

To reduce errors, hospitals are increasingly turning to checklists -- and a growing body of research shows they work.

A study in the Oct. 20 issue of the Journal of the American Medical Association found that a program at 108 Veterans Administration hospitals that involved pre- and post-surgical debriefings as well as checklists reduced deaths by 18 percent.

In the new study, all participating hospitals, which included both academic and teaching hospitals, were highly regarded before implementation of the checklists, showing that even high-performing hospitals can benefit, Boermeester noted.

After implementing the checklists, complications fell from 27.3 per 100 patients to 16.7 per 100. The proportion of patients with one or more complications fell from 15.4 percent to 10.6 percent, while the in-hospital death rate fell from 1.5 percent to 0.8 percent.

Patient outcomes did not change at hospitals used as controls.

Dr. John Birkmeyer, a surgeon and director of the Center for Healthcare Outcomes and Policy at the University of Michigan, said the study provides strong evidence that checklists aren't merely a good idea, but something that all hospitals should be using as a "best practice."

"This study confirms previous research that showed the use of checklists can have a dramatic effect in both reducing the risk of dying after surgery and suffering other types of complications," Birkmeyer said. "There is enough evidence that has accrued about the effectiveness of checklists that I believe they have crossed a threshold beyond just being a good idea and to becoming a standard of surgical care."

Not only did the checklists reduce the specific complications targeted by line items on the checklist (such as having blood available or giving the right antibiotics before surgery), but they reduced all types of complications after surgery.

"This implies checklists work less because of specific content, but more because of the indirect effects on teamwork, communication and other aspects of safety culture," said Birkmeyer, who wrote an accompanying editorial in the journal.

More information

The Agency for HealthCare Research and Policy has tips on protecting yourself from medical errors.

SOURCES: Marja Boermeester, M.D., Ph.D., gastrointestinal surgeon, Academic Medical Center, Amsterdam, the Netherlands; John Birkmeyer, M.D., director of the Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor; Nov. 11, 2010, New England Journal of Medicine

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