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Research by Marty Stempniak

Patient safety in the operating room has been a persistent topic of conversation in the health care business. Still, certain seemingly avoidable mistakes — such as operating on the wrong body part or giving an improper medication — continue to occur.

Last year alone, there were 152 cases of surgeons operating on the wrong patient, or wrong site, or performing the wrong procedure, according to the Joint Commission. Another 27 happened in the first quarter of 2012.

"Those numbers tend not to support that safety in the operating room has increased significantly," says Ana Pujols McKee, M.D., executive vice president and chief medical officer at the Joint Commission. "However, at the same time, that's a dangerous number because we've made more progress in reporting, so the number could actually reflect that we're being more consistent."

Some of the nation's best-known experts in surgery, such as Atul Gawande, M.D., have pushed to make checklists the norm in operating rooms across the country. By acting like airline pilots and taking each part of the surgery one step at a time, they say, the checklist can help hospitals dramatically reduce surgical infections, major complications and deaths.

A Harvard-based group called Safe Surgery 2015, led by Gawande, aims to have all operating rooms in the world using the World Health Organization's Surgical Safety Checklist program by 2015. Numerous versions of the checklist now exist, and the group offers a template on its website to help hospitals tailor it to meet their needs.

After a few years of getting the initiative rolling, Bill Berry, program director for Safe Surgery and surgical consultant to the Risk Management Foundation of the Harvard Medical Institutions, estimates that the list has reached maybe 25 percent of U.S. hospitals. It's getting a big push in South Carolina, where already about 35 hospitals in the state, from large academic institutions to critical access hospitals, are using the list. The goal is full implementation in the state by 2013. Safe Surgery expects it will save 500 lives a year in South Carolina.

Berry admits the goals nationally are "very, very ambitious," but he believes a groundswell is starting to build as more checklist-related campaigns pop up around the country.

The Centers for Medicare & Medicaid Services, for example, made it mandatory to use a surgical safety checklist for Medicare patients in ambulatory surgery centers back in January. Berry calls that a major step, although checklists still are not mandated in acute care settings. The Agency for Healthcare Research & Quality, along with Johns Hopkins University, is working to take the surgical checklist to 10 states and at least 10 hospitals in each state over the next few years.

One of the biggest barriers has been getting surgeons to accept the checklist as a tool. "My key to the lock to hospitals, when they ask me what I should do, is to talk to the surgeons," Berry says. "And I don't mean send them emails or put posters on the wall or that kind of stuff. I mean talk to them." Some say the CEO should do the talking, others say a fellow surgeon would be more effective. "I personally believe there are a lot of people who can have those conversations," Berry says.

But checklists alone aren't enough, experts say. Communication and team building are essential ingredients in the operating room. The Veterans Health Administration's National Center for Patient Safety found significantly better surgery outcomes for hospitals that put their staff through team training, according to one recent study. Some 80 percent of adverse events are attributable to failed communication, notes Gary Sculli, director of clinical training programs and program manager at the NCPS.

"We know it's a problem. And when you're doing surgery, which is a high-risk area anyway, why would anyone take a chance on not improving communication?" Sculli says.

This gatefold explores some of the most prevalent problems in the OR and what causes them, the idea of a surgical safety checklist, and improving communication and teamwork in the surgical team.

Ways to build teamwork in the OR

For surgeons

  • Activate people by using their name.
  • Set the tone — make everyone feel safe.
  • Tell the team what you're going to do.
  • Encourage team members to speak up.
  • Stop the debrief at the end of the case.

For leadership

  • Don't try to "fix" surgeons with the checklist.
  • Ask a person the surgeons respect to talk with them in one-on-one conversations before you hold large or discipline-specific meetings about the checklist.
  • Don't force surgeons to use the checklist initially.
  • Ask surgeons not to influence anyone else against using the checklist.

Source: Safe Surgery 2015: South Carolina, 2012

Safe surgery 2015 checklist template

1. Before induction of anesthesia

Nurse & anesthesia provider verify:

  • Patient ID (name, date of birth)
  • Surgical site
  • Surgical procedure to be performed matches consent
  • Site marked
  • Known allergies
  • Patient positioning
  • The anesthesia safety check has been completed

Anesthesia provider shares patient-specific info with team:

  • Anticipated airway or respiration risk
  • Risk of significant blood loss
  • Two IVs/central access and fluids planned
  • Type of cross-match/screen
  • Blood availability
  • Risk of hypothermia — for operations longer than 1 hour
  • Warmer in place
  • Risk of venous thromboembolism
  • Boots and/or anticoagulants in place


Entire surgical team:

  • Is everyone ready to perform the time-out?
  • Please state your name and role
  • Patient's name
  • Surgical procedure to be performed
  • Surgical site
  • Essential imaging available
  • Has antibiotic prophylaxis been given within the last 60 minutes?
  • Plan for re-dosing discussed


Surgeon shares:

  • Operative plan
  • Possible difficulties
  • Expected duration
  • Anticipated blood loss
  • Implants or special equipment needed

Anesthesia provider shares:

  • Anesthetic plan
  • Airway concerns
  • Other concerns

Circulating nurse and scrub tech share:

  • Sterility, including indicator results
  • Equipment issues
  • Other concerns


Nurse reviews with team:

  • Instrument, sponge and needle counts are correct
  • Name of procedure performed
  • Specimen labeling
  • Read back specimen labeling including patient's name


Entire surgical team discusses:

  • Equipment problems that need to be addressed
  • Key concerns for patient recovery and management
  • What could have been done to make this case safer or more efficient?

Source: Safe Surgery 2015 and the Health Research & Educational Trust. The checklist is not meant to be comprehensive, and additions and modifications are encouraged, according to Safe Surgery 2015.

Who should be on your checklist implementation team?

  • Administrator/quality improvement officer
  • Anesthesiologist and/or CRnA
  • Circulating nurse
  • Scrub tech
  • Surgeon
  • others (perfusionists, biomedical engineers, anesthesia techs, pAs, pre-op nursing, etc.)

Source: Safe Surgery 2012

Catching mistakes before they make it to the operating room

Catching preventable problems in the operating room, such as wrong-site surgery, means keeping a watchful eye over the patient from scheduling all the way to discharge, according to the Joint Commission. This graphic shows how small errors can penetrate multiple layers of a hospital's defense and lead to a serious event.

Most common types of errors

Here's a look at some of the most common OR errors as voluntarily reported to the Joint Commission from 2004 through the first quarter of 2012. All were classified as sentinel events, involving serious physical or psychological injury.

Wrong patient, wrong site or wrong procedure, 846 total (152 in 2011)

  • Leadership (83%)
  • Communication (69%)
  • Human factors (65%)
  • Information management (36%)
  • Operative care (35%)

Unintended retention of foreign objects, 700 total (188 in 2011)

  • Leadership (80%)
  • Communication (65%)
  • Human factors (63%)
  • Operative care (57%)
  • Assessment (25%)

Op/Post-op complications, 655 total (133 in 2011)

  • Human factors (61%)
  • Communication (55%)
  • Assessment (50%)
  • Leadership (42%)
  • Information management (20%)

Possible at-risk behaviors in the operating room

  • Not checking the equipment before it is used
  • Having a surgeon enter the OR after the patient is prepped and draped
  • Having a surgeon run two different rooms at the same time
  • Multitasking from the OR
  • Relying on memory about the pathology
  • Unlabeled clear solutions on the back table
  • Not properly washing hands
  • Using electrosurgical Bovie devices in an oxygen-rich environment
  • Unannounced substitutions in the middle of a case
  • Continuing to close up the patient during a sponge search

Source: John R. Clarke, M.D., clinical director for patient safety and quality initiaties, ECRI Institute, 2007

Case Study

Boston Children's Hospital

Boston Children's Hospital adopted its own version of the World Health Organization's Surgical Safety Checklist for pediatric populations. A pilot project using the checklist started in 2009 and found improvements in teamwork, communication and adherence to process measures.

  1. Keys to effective implementation of a checklist policy:

    1. Senior leadership support
    2. Nursing and physician champions
    3. Hospitalwide committee to figure out edits and roll out the checklist beyond the OR
    4. Committee of clinicians, representing nurses and doctors, to develop the list
    5. Pilot checklist with early adopters
    6. Edited checklist based on feedback
    7. Ongoing log of near-miss or saves related to checklist
    8. Education plan that includes in-services to all disciplines
    9. Electronic education, sent to all clinicians participating in invasive procedures
    10. Monthly "live" audits
    11. Regular feedback to staff and continued education

Afterward: Boston Children's worked to trim its checklist to make it shorter and more concise, gathering input from staff before making changes. The initial test period was two months, with edits made after each trial. One month after implementation in the OR, Boston Children's spread it to all areas of the hospital performing invasive procedures. It has three different checklists: for ORs, procedural areas and bedside procedures. One hundred percent of surgical teams are using the checklist at Boston Children's.

Source: Boston Children's Hospital and the Institute for Healthcare Improvement, 2010

How We Did It:

This gatefold was produced by researching published studies and articles and conducting interviews with hospital and industry executives.

Research: Marty Stempniak,
Design: Chuck Lazar,