Why Questioning Overwhelming Study Results can be Interesting: The Surgical Checklists

In 2009 Haynes at al. published an article in the NEJM reporting large improvements in surgical safety when adapting the use of a standardized checklist issued by the WHO in 2008. Over the period of almost one year they looked at 8 hospitals, in 8 cities, on 7 continents. A total of 3733 patients that underwent non-cardiac surgery were enrolled to compare before and after introducing the Surgical Safety Checklist.

The 2009 study found a 47% reduction in deaths associated with high-risk surgeries when the checklist was used. The rate of surgical site infections was almost cut in half and there was a significant reduction in overall complications (by 36%) and unplanned returns to theatre… Wow!

The study group concluded that the checklist program has the potential to prevent large numbers of deaths and disabling complications… ‘although further study is needed to determine the precise mechanism and durability of the effect in specific settings’

And further study has been done now. Urbach et al. now has published a special article, again in the NEJM. This time they surveyed all acute care hospitals in Ontario, Canada, before and after adopting surgical safety checklists. During 3 months 101 hospitals performed 109’341 (before) and 106’370 (after) surgical procedures.

In this study no significant reduction in operative mortality or complications was found… Oh!

So are these checklists for no use at all or is there another explanation for these different findings? The author, Dr. Urbach, says himself that checklists are here to stay and are helpful in theatre, but that he is hopeful it will serve as a bit of a reality check to say that ‘You know it’s not this easy to create major improvements in what really is a large and complex problem’ (The Canadian Press).

It also shows that checklists itself are not the only solution for problems with patients safety… especially in a time where checklists are introduced everywhere… yes, everywhere!

Haynes et al. N Engl J Med 2009; 360:491-499

Urbach et al. N Engl J Med 2014; 370:1029-1038

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