Experience with the implementation of the WHO checklist and briefing in the operating theatre. Krishna Moorthy. IV Internacional Conference on Patient Safety. (Madrid, Ministry of Health and Consumer Affairs, 2008)

1. Improving safety and teamwork in
the operating theatre
Krishna Moorthy
Senior Lecturer and Consultant
Upper GI Surgeon

2. Incidence of Surgical Adverse
Events
Country/
Study
N Year AE Surgical
AE
Preventable
Harvard
(HMPS)
30,195 1991 3.7% 50% 50%
USA
(UT/CO)
15,000 2000 2.9% 50% 50%
UK 1014 2001 10.8% 71.8% 55%

3. Wrong site/
operation/
patient
Scale of the problem
• 1 in 50,000
procedures in the
USA
• 1500 to 2500 cases/
year
Kwaan et al. Arch Surg. 2006;141: 353-8

4. Rare!!!!
Wrong site surgery- 2500 per year of 75 million
procedures in the US-0.0003%
10 million flights per year in the US
In aviation- this would translate to
1 crash per day

5. SSI
Bratzler, D. W. et al. Arch Surg 2005;140:174-182.

6. Teamwork
Pre-op Intra-op Post-op
Surg Urol Surg Urol Surg Urol
Equip 56% 61% 82% 91% 89% 95%
Comm 61% 71% 55% 57% 90% 84%
Patient 90% 94% 93% 93% 97% 92%

7. Team tas k P f d
N
5 Surgeon briefs team abo ut proced ure 24 76
11 Team communicate about Antibiotic prop hylaxis 32 68
The team discussed equipment needs- 18-22% of
cases
Antibiotic prophylaxis was discussed- 32% cases
DVT prophylaxis was checked- 10% of cases
Scrub nurses informed surgeon of swab, instrument and
needle count in 16% of cases although performed counts
in 100% of cases
Team confirmed patient identity, procedure and site- 8-
16% of cases

9. SURGICAL SAFETY CHECKLIST
(DRAFT)
SAFE SURGERY SAVES LIVES
GLOBAL PATIENT SAFETY CHALLENGE
WORLD HEALTH ORGANISATION
SIGN IN – PRIOR TO INDUCTION OF ANAESTHESIA, VERIFY:
□ PATIENT CONFIRMED IDENTITY, SITE, PROCEDURE AND CONSENT
□ SITE MARKED/NOT APPLICABLE
□ ANAESTHESIA SAFETY CHECK COMPLETED
□ PULSE OXIMETER ON PATIENT AND FUNCTIONING
DOES PATIENT HAVE A:
KNOWN ALLERGY
□ NO □ YES
DIFFICULT AIRWAY/ASPIRATION RISK
□ NO □ YES, AND NEEDED EQUIPMENT AND ASSISTANCE AVAILABLE
RISK OF >500CC BLOOD LOSS (7CC/KG IN CHILDREN)
□ NO □ YES, AND ADEQUATE IV ACCESS AND FLUIDS PLANNED
TIME OUT – PRIOR TO SKIN INCISION:
□ CONFIRM ALL TEAM MEMBERS HAVE INTRODUCED THEMSELVES BY NAME D ROLE
□ SURGEON, ANAESTHETIST AND NURSE VERBALLY CONFIRM PATIENT NAM OCEDURE, AND SITE
ANTICIPATED CRITICAL E
□ SURGEON REVIEWS: W IVE DURATION? ANTICIPATED BLOOD LOSS?
□ ANAESTHESIA TEAM R -
□ NURSING TEAM REVIE ISSUES OR ANY CONCERNS?
ANTIBIOTIC PROPHYLAXIS GI
□ YES □ NOT A
ESSENTIAL IMAGING DISPLAYED
□ YES □ NOT APPLICABLE
SIGN OUT – PRIOR TO THE PATIENT LEAVING THE OPERATING TH TRE:
NURSE VERBALLY CONFIRMS WITH THE TEAM:
□ THE NAME OF THE P
□ THAT INSTRUMENT, CABLE)
□ HOW THE SPECIMEN
□ WHETHER THERE AN
SURGEON, ANAESTHESIA PROFESSIONAL AND NURSE REVIEW:
□ WHAT ARE THE KEY CONCERNS FOR RECOVERY AND MANAGEMENT O IS PATIENT?
_______________________________ ______________
SIGNATURE (ON BEHALF OF ENTIRE TEAM DATE
FOR PURPOSES OF QUALITY IMPROVEMENT ONLY)
•Patient identification
•Highlights anaesthetic risks
•Allergic reactions
•Patient identification
•Highlights anaesthetic risks
•Allergic reactions
• Wrong site surgery
• antibiotic prophylaxis
• Equipment problems
• shared mental model
• specimen mislabelling
• counts

10. 8 Pilot Sites
PAHO II
Seattle, USA
London, UK
EURO EMRO
Amman, Jordan
WPRO I
SEARO
AFRO
PAHO I
Toronto, Canada
New Delhi, India
Manila, Philippines
Ifakara, Tanzania
WPRO II
Auckland, NZ

11. WHO Checklist project
Data collection
360 patients
Checklist
Data collection
360 patients
• Measures: Processes and clinical outcome
(complications and LOS)

12. I/V antibiotics
Pre-checklist Post-checklist
Antibiotics
80%
20%
Given
Not given

13. Antibiotic timing
Pre-checklist Post-checklist
52%
14%
3%
31%
71%
7%
2%
20% in time
after incision
over 60 min
No
antibiotics

14. Patient outcomes
15
45
4
7
15
1
0
5
10
15
20
25
30
35
40
45
50
Pre‐checklist
Post‐checklist
Surgical site Other Death
infection complications

15. g spec ig
5 Surgeon briefs team abo ut proced ure 24 76
11 Team communicate about Antibiotic prop hylaxis 32 68
The team discussed equipment needs in 70% of
cases (vs 20%)
Antibiotic prophylaxis was discussed in all cases (vs 32%)
DVT prophylaxis was discussed in only 50% of cases (vs 10%)
Scrub nurses informed surgeon of swab, instrument
and needle count in 85% (vs 16%) of cases although
performed counts in 100% of cases
Team confirmed patient identity, procedure and
site in100% of cases (vs 15%)

16. Benefits of the WHO checklist
• Reduces assumptions
“When we have an adverse event and we talk
to people, they will say....I assumed that
somebody had checked”
• Adds redundancy to safety processes
“There is no excuse for getting halfway through the operation and
somebody discovering that we don’t have the right instruments. It is
unthinkable but it still happens ”

17. • Improves teamwork and communication
“I always wondered who these people were in the theatre that I
was working with sometimes but being busy you wouldn’t
approach them but you know that they are part of team.........now
( with WHO checklist use) I understand their role better”
“There is a terrible tendency for the team actually not being a
team----realisation that we are a team”

18. Compliance
18

19. Reasons
• Effectiveness?
• Hierarchy
• The timing of the checks
• Viewed as increased work load- yet
another checklist
• Only if everybody is on board
• No improvement
perceived in surgical
team efficiency
(Interview study underway, Imperial
College, 2008)

20. Perceived limitations
“ Has it improved equipment availability, has it improved
anticipation of problems and so on..... Rather than the
actual...... Has right box been ticked”
“It sounds a bit artificial sometimes. Its trying to be
everything to every nation and to every standard of
medicine”
“It is a very different way of communication for many
people”

21. Increase uptake and compliance
• Demonstration of its effectiveness
“ If you can demonstrate to a surgeon that 10 minutes
spent in the beginning of the list-----will actually go
smoothly without headaches......and they may get an extra
case done”
• Organisational modification
• Organisational and clinical leadership
• Training- changing the culture
• Public awareness and media pressure

22. UK- next steps

23. Issues
• Content of the checklist
• Ownership and signatures
• In patients notes
• Mandated or not?

24. SURGICAL SAFETY CHECKLIST
(DRAFT)
SAFE SURGERY SAVES LIVES
GLOBAL PATIENT SAFETY CHALLENGE
WORLD HEALTH ORGANISATION
SIGN IN – PRIOR TO INDUCTION OF ANAESTHESIA, VERIFY:
□ PATIENT CONFIRMED IDENTITY, SITE, PROCEDURE AND CONSENT
□ SITE MARKED/NOT APPLICABLE
□ ANAESTHESIA SAFETY CHECK COMPLETED
□ PULSE OXIMETER ON PATIENT AND FUNCTIONING
DOES PATIENT HAVE A:
KNOWN ALLERGY
□ NO □ YES
DIFFICULT AIRWAY/ASPIRATION RISK
□ NO □ YES, AND NEEDED EQUIPMENT AND ASSISTANCE AVAILABLE
RISK OF >500CC BLOOD LOSS (7CC/KG IN CHILDREN)
□ NO □ YES, AND ADEQUATE IV ACCESS ND FLUIDS PLANNED
TIME OUT – PRIOR TO SKIN INCISION:
□ CONFIRM ALL TEAM MEMBE LE
□ SURGEON, ANAESTHETIST URE, AND SITE
ANTICIPATED CRITICAL EV
□ SURGEON REVIEWS: W URATION? ANTICIPATED BLOOD LOSS?
□ ANAESTHESIA TEAM R -
□ NURSING TEAM REVIE T ISSUES OR ANY CONCERNS?
ANTIBIOTIC PROPHYLAXIS GIV
□ YES □ NOT AP
ESSENTIAL IMAGING DISPLAYED
□ YES □ NOT APPLICABLE
SIGN OUT – PRIOR TO TH :
NURSE VERBALLY CONFIRM
□ THE NAME OF THE PR
□ THAT INSTRUMENT, S LE)
□ HOW THE SPECIMEN IS
□ WHETHER THERE ANY E
SURGEON, ANAESTHESIA PROFESSIONAL AND NURSE REVIEW:
□ WHAT ARE THE KEY CONCERNS FOR RECOVERY AND MANAGEMENT HIS PATIENT?
_______________________________ ______________
SIGNATURE (ON BEHALF OF ENTIRE TEAM DATE
FOR PURPOSES OF QUALITY IMPROVEMENT ONLY)
Drop pulse oximetryDrop pulse oximetry
checks
• Prior to draping
•Two identifiers
•Add DVT prophylaxis check
• Temperature maintenance check
•Flexibility to add specialty specific
checks
• Prior to closure of skin incision

25. Make it ‘stick’- national campaigns
• Existing systems for prevention of wrong
site surgery
• Improve compliance with High Impact
Intervention #4 (reducing SSI) of the
Saving Lives Campaign
• Prevention of DVT

26. Acknowledgments
• Amit Vats, Kamal Nagpal- research fellows
• Boston- Dr Atul Gawande, Tom Weiser,
Alex Haynes, Dr Bill Berry
• World Health Organisation (WHO)
• Rachel Davies
• Prof Charles Vincent
• Prof Lord Ara Darzi