To Check(list) or Maybe Not?

You probably read Atul Gawande's 'The Checklist Manifesto', in which he talks about how the safe surgery checklist came to life. I enjoyed the read especially as it seemed to have come to fruition so unexpected and yet so logical. And of course, as with anything related to quality improvement, the part that was the most challenging was yet to come: implementation.

It has been now 6 years since the WHO published the first edition of the Safe Surgery Checklist Implementation manual, and so far it has been widely adopted in hospitals around the globe. Sometimes, regulations and mandates have been used to ensure compliance.

Then, in March 2014, a study in the NEJM conducted by a group of Ontario researchers concluded that the implementation of the checklist was not associated with 'significant reductions in surgical mortality and complications'. And the debate started: what are we to make of this? Although it is a checklist, the obvious fact is that not ticking the boxes is what makes the surgery safe, but performing those actions. Also, implementation of this tool is hard, in an area where tradition is strong, egos are big and change is difficult. When hospitals are under pressure to conduct audits for compliance, how truthful are those audits? Another study looking at the OR and PACU safety culture in comparison with other hospital units concludes that the OR/PACU actually score lower than other hospital units, which means the OR is an area where improvements on the understanding of safety culture is much needed. We first need to understand what a safety culture is, in order to really successfully apply tools to improve this culture.