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In health care, as in other industries, most errors are caused by slips rather in which a checklist of evidence-based infection control interventions was the use of checklists to improve safety at the time of hospital discharge.
Table of contents

The operating room is an appropriate educational environment, but the presence of observers at any level must not be allowed to compromise patient safety. Patient safety in surgery demands the full attention of skilled individuals using well-functioning equipment under adequate supervision. All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, posted on the Internet, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without prior written permission from the publisher.

Patient safety in the surgical environment. Committee Opinion No. American College of Obstetricians and Gynecologists. Obstet Gynecol ;— Women's Health Care Physicians. This document reflects emerging concepts on patient safety and is subject to change. The information should not be construed as dictating an exclusive course of treatment or procedure to be followed. Introduction Potentially preventable surgical errors have received increasing attention in recent years, although they appear to occur relatively infrequently compared with other types of medical errors.

Terminology The term wrong-site surgery is used to refer to any surgical procedure performed on the wrong patient, wrong body part, wrong side of the body, or at the wrong level of the correctly identified anatomic site 2. The following terms can be used to describe the various specific errors: Wrong-patient surgery describes a surgical procedure performed on a different patient than the one intended to receive the operation.

Wrong-side surgery indicates a surgical procedure performed on the wrong extremity or side of the patient's body eg, the left ovary rather than the right ovary. Wrong-level surgery and wrong-part surgery are used to indicate surgical procedures that are performed at the correct operative site, but at the wrong level or part of the operative field or patient's anatomy.

Systems Approach Particularly because of the potential for serious harm from surgical errors, vigorous efforts are required to eliminate or reduce their frequency. The Joint Commission has identified the following factors that may contribute to an increased risk of wrong-site surgery: Multiple surgeons involved in the case Multiple procedures during a single surgical visit Unusual time pressures to start or complete the procedure Unusual physical characteristics, including morbid obesity or physical deformity A common theme in cases of wrong-site surgery involves failed communication between the surgeon s , the other members of the health care team, and the patient.

The universal protocol, now included in the chapter on national patient safety goals in the Joint Commission's accreditation manual, involves the completion of three principal components before initiation of any surgical procedure 3 : Preprocedure verification process The health care team ensures that all relevant documents and related information or equipment are available before the start of the procedure; correctly identified, labeled, and matched to the patient's identifiers; and reviewed and are consistent with the patient's expectations and with the team's understanding of the intended patient, procedure, and site.

The team must address missing information or discrepancies before starting the procedure. Marking the operative site Procedures that require marking of the incision or insertion site include those where there is more than one possible location for the procedure or when performing the procedure would negatively affect quality or safety. According to the Joint Commission, the site does not need to be marked in cases where bilateral structures such as ovaries are removed 3.

Although the Joint Commission does not require a specific site marking method, each facility should be consistent in the method it uses ensuring that the mark is unambiguous.

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World Health Organization Surgical Safety Checklist Another useful tool to promote patient safety in the surgical setting is the surgical safety checklist published by the World Health Organization. Patient Involvement A relatively new but essential element of the overall process is the formal enlistment of the patient in the effort to avert errors in the operative arena. Granting Privileges for New Procedures New techniques and new equipment are important components for developing and delivering the best quality care in the operating room, but they also represent sources of potential surgical error.

Stress and Fatigue A well-recognized source of human error is excessive stress and fatigue. Medication Errors The surgical environment deserves heightened vigilance to prevent medication errors because medication orders often are given verbally rather than in writing, making such orders particularly vulnerable to misinterpretation or misapplication.

Retained Foreign Objects The Joint Commission includes unintended retention of a foreign object in a patient after surgery or other procedure as a reviewable sentinel event Teaching Trainees, such as obstetric—gynecologic residents, surgical residents, anesthesiology residents, medical students, nursing students, and operating room technician students, may be part of the surgical environment in the operating room or labor and delivery suite.

Patient Safety film

Obstetric Surgery Operating on pregnant patients creates unique responsibilities in ensuring patient safety because two or more patients are involved simultaneously—the woman and the fetus es —each with different needs. Freestanding Surgical Units In recent years, many surgical procedures traditionally performed only in hospitals or similar institutions have increasingly been performed in physicians' offices or freestanding surgical facilities. Distractions Beepers, radios, telephone calls, and other potential nonessential activities and distractions in the surgical environment should be kept to a minimum, if allowed at all, especially during critical stages of the operation.

Conclusion Although medical errors can occur in any aspect of medicine, the surgical environment presents additional, special challenges to safeguarding patient safety. References The Joint Commission. Sentinel events statistics.

Implementation Guide | Agency for Healthcare Research & Quality

April 30, The Joint Commission. Universal protocol for preventing wrong site, wrong procedure, and wrong person surgery. Retrieved April 30, National patient safety goals NPSG. In: Comprehensive accreditation manual. CAMH for hospitals: the official handbook. World Health Organization. Surgical safety checklist. Geneva: WHO; Health and Safety Executive UK. Human factors: fatigue. National Highway Traffic Safety Administration.

The dangers of drowsy driving—some startling statistics. Accreditation Council for Graduate Medical Education. Common program requirements: VI. Resident duty hours in the learning and working environment. Sleep, fatigue, and medical training: setting an agenda for optimal learning and patient care. One study stated that "there were other efforts during the study period to improve ventilator care and reduce catheter-related infections that may have contributed to reduced LOS" [ 7 ].

Most studies did not provide evidence of how they measured if staff were using the checklists properly during their work.


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All studies used some sort of staff training or education to increase compliance and proper use of the checklists, but it is unclear if the education and training was effective as this was not assessed in any of the studies. Apart from assessors being there to observe staff doing their work and using the checklists, which one study did [ 5 ], one did part of the time [ 10 ], or allowing other staff to check each other's checklist before proceeding with further actions [ 4 , 10 , 12 ], there were no other methods to ensure that staff were using the checklists properly.

It is also unclear if there is an optimal design of checklists for specific tasks. In most studies the checklist itself was not validated prior to implementation. Validation of the checkilist is important to ensure that the list contains all relevant items, no unnecessary items and that the included items are interpreted accurately and consistently by the users.

For example, one study states that "it is not clear that each element of the checklist needed to be there" [ 5 ]. There were different outcome measurement periods between treatment groups.

The longest period between control and intervention assessments for any study was 12 months [ 3 ]. In one study in the ED setting there was a very large difference in the observation periods between the control period three months and the intervention period four weeks [ 9 ]. Outcomes were not uniformly defined across all studies, even relatively well accepted outcomes such as LOS defined and measured in different ways [ 3 , 6 , 7 ]. Assessment of LOS is also complex as it is not usually normally distributed as assumed in some of the studies, in some studies was measured differently after checklist implementation and the link between LOS and other surrogate outcome measures to the outcome of patient safety is also unclear [ 4 , 6 ].

It is also questionable whether improvements in staff communication and protocol adherence translate directly to improvements in patient outcomes [ 4 , 6 , 9 ]. It may be incorrect to draw direct links between improved staff communication and protocol adherence and better patient outcomes from any of these studies because we do not know all the characteristics of the patient population that was studied and all other patient care factors.

It is also unclear how long after the introduction of the safety checklist outcome assessment should start. One study defined proper checklist use as being when the intervention had been implemented for 60 days [ 11 ]. This is an arbitrary point and it is unclear if the 60 day period after the implementation of the intervention can be validly used as a cut-off point. Inclusion of a comprehensive education and training package could increase the optimal use of the intervention earlier. However, studies could also measure outcomes too early and give a false impression of ineffectiveness.

The dilemma for healthcare providers is to measure the outcomes as soon as possible, but making sure that the intervention has been properly integrated into clinical practice first. It was unclear if there was a relationship between the effect of using a checklist and time, however most studies only assessed outcomes for a few months. Caution should be exercised when extrapolating any reported short-term outcomes from the studies to longer term predictions about effectiveness.

Longer outcome assessments of maybe at least one year, or over a few cycles of staff changes, may be needed to determine the sustainability of changes. This review has some limitations.

Patient safety checklists

Only comparative studies written in English since were considered, so potentially relevant studies published in other languages or prior to may have been missed. We also did not have the resources to hand-search information sources or contact individual hospitals or experts for potentially relevant studies or evaluations of checklist programs. However our search was broad, and we included a wide variety of checklists in a broad range of patient care settings. The included studies were undertaken in a variety of settings, used varying methods and evaluated differing interventions and outcomes.

As a result we were unable to undertake a statistical meta-analysis, however we believe our detailed quality appraisal and narrative synthesis highlights the strengths, weaknesses and key messages of this complex body of literature.


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  6. Some studies remarked that some of the items in their own checklists were probably unnecessary. To determine the most useful design and content of checklists clinical trials comparing different checklist designs and content within the same settings are required. There are Cochrane systematic review protocols to review the evidence on the effect of computer-generated paper reminders [ 13 ] and paper reminders on practice and healthcare outcomes [ 14 ] but these are looking at a broader range of interventions and outcomes.

    A more recent published evaluation of the WHO surgical checklist was published in [ 15 ]. There has been a retrospective publication of an 8 year use of safety checklists in neurosurgery [ 16 ], and we hope this will result in more publications of long-term comparative studies in this area, both retrospective and prospective studies.

    In conjunction with this systematic review, Southern Health designed and implemented a medical safety checklist for use by clinical staff and has been monitoring its effect on clinical outcomes. Results from this pilot work at Southern Health may help inform the body of evidence for using safety checklists to improve safety. Concurrently, Southern Health is looking at piloting the use of electronic checklists in improving patient safety. Southern Health plans to update this current systematic review in , and add an appraisal of the evidence for electronic checklists. Resource use should also be considered, such as staff time and funding requirements to properly provide training and education for using the checklists.

    Health services piloting new checklists or using established checklists should be encouraged to create an evaluation plan on their use of safety checklists and publish their findings so that the body of evidence can grow. From nine studies in four hospital care settings, there was no high level evidence showing the effectiveness of safety checklists. These studies suggest some benefits of using safety checklists to improve protocol adherence and patient safety, but the studies had a moderate to high risk of bias so their results should be interpreted with caution.

    More high quality and high level studies, are needed to enable more confident conclusions about the effectiveness of safety checklists in acute hospital settings. This systematic review was done as part of normal operational services provided to Southern Health by the Centre for Clinical Effectiveness.