1. Checklists, Consistency, & Charting
Paige Klem

2. Development of a checklist
Derived by the success in aviation and pilots
‘Pause Points’
Should be team focused to communicate
Precise; Efficient, and to the point
Poor communication is the single most frequent cause of adverse events
“They do not try to spell out everything– a checklist cannot fly a plane. Instead, they provide reminders of only the most critical and important steps—the ones that even the highly skilled professionals using them could miss” (Gawande, 2010, p. 120).
Gawande, Pg Aviation developed ‘pause points’ where the team must run through checks before proceeding.

3. The Checklist Manifesto: How to Get Things Right By: Atul Gawande
Goals of a checklist:
Foster teamwork, huddle
Introduction of names
Verbal, team checklist
Create consistency among teams
Page : about ½ the time, the staff does not know each other names; “When nurses were given a chance to say their names and mention concerns at the beginning of a case, they were more likely to note problems and offer solutions. The researchers called it an ‘activation phenomenon.’ Giving people a chance to say something at the start seemed to activate their sense of participation and responsibility and their willingness to speak up” (p. 108).

4. Institution of WHO Surgical Checklist
Trialed worldwide at 8 hospitals:
↓ 36% in all major complications
↓ 47% in deaths
Infections decreased by almost half
Returns to OR decreased by 1/4th
Catches
Antibiotic delivery or allergies
Pre-existing medical problems
Gawande Pg
Page 189- the catch

5. Broken down into 3 ‘pause points’

6. Consistency With Practice
Know your role
Practice within your scope
Be routine with steps
Allows steps not to get missed
Incorporate checklists into your routine
Allows you to handle unexpected situations
Story on page

8. Charting Inclusions Initial assessment
Including identity of patient
Surgical site marked
Times- arrival, start, completion, exit
Disposition of devices/aids
Glasses, prosthetics
Position
Safety devices, restraints
Equipment identifiers
ESU
Tourniquet
Names and times of personnel
Level of anesthesia
Surgical site prep
Medications/solutions used
Timeout
Procedure done
Contact with family/caretaker
Implants identifying info
Radiology/imaging use
Specimens and disposition
Surgical count
Drains, catheters, dressings, packing, etc
Wound classification
Charges
Disposition of patient
Complications
B&K pg 481

9. Additional charting items
Significant or major breaks in sterile technique
Affects the wound classification
Equipment used
ESU
Settings
Identifiers- ex. Biomed #
Skin condition
Tourniquet
Limb occlusion pressure, if applicable
Cuff pressure and inflation times
Skin protection measures and assessment
Radiation protective measures
Measures taken to prevent RSI and counts
DVT prophylaxis
Transfer mechanism or devices used
AORN: p 89, 132, 340, 357,

10. Charting tips
Should reflect the ongoing evaluation of the perioperative care and outcomes
Chart the same way every time
Acts as communication between providers
Factual and objective information
To display the patients experience
Document with the flow of nursing care
Do not double chart in multiple areas
Avoid unnecessary narratives
Be familiar with downtime forms
B&K p. 32; AORN pg 89, 492

11. Surgical Wound Classification Algorithm
Surgical wound classification can change throughout the case based on the change in procedure, cross into bowel, or break in sterile technique.

12. SURGICAL WOUND CLASSIFICATION45
Description
Examples of procedure type
Class I: Clean (1% to 5% risk of infection)
Uninfected operative wound in which no inflammation is encountered and the respiratory, alimentary, genital, and uninfected urinary tracts aren't entered
Primarily closed and, if necessary, drained with closed drainage
Operative incisional wounds that follow nonpenetrating (blunt) trauma if they meet the criteria
Inguinal hernia repair, ventral hernia repair, thyroidectomy, exploratory laparotomy, mastectomy, neck dissection, total knee or hip replacement, craniotomy, laminectomy
Class II: Clean-contaminated (4% to 10% risk of infection)6
Operative wound in which the respiratory, alimentary, genital, or urinary tracts are entered under controlled conditions and without unusual contamination
Operations involving the biliary tract, appendix, vagina, and oropharynx provided no evidence of infection or major break in technique is encountered
Bronchoscopy, laryngoscopy, cholecystectomy (open or laparoscopic approach), appendectomy, small-bowel resection, gastrectomy, transurethral resection of the prostate, cystoscopy, pancreaticoduodenectomy (Whipple), total abdominal hysterectomy, vaginal hysterectomy
Class III: Contaminated (greater than 10% risk of infection even with prophylactic antibiotics)6
Open, fresh, accidental wounds
Operations with major breaks in sterile technique (such as open cardiac massage) or gross spillage from the GI tract
Incisions in which acute, nonpurulent inflammation is encountered
Unplanned open cardiac massage (chest incision made without skin preparation or drape), appendectomy for appendicitis, bile spillage during cholecystectomy, diverticulitis, dry gangrene (tissue death without infection) in which nonpurulent inflammation is present
Class IV: Dirty (infected) (greater than 27% risk of infection)6
Old traumatic wounds with retained devitalized tissue and those that involve existing clinical infection or perforated viscera
Suggests that the organisms causing postoperative infection were present in the operative field before the operation
Incision and drainage of abscess, myringotomy for otitis media, perforated bowel, peritonitis, gangrenous wound with purulent drainage

14. Reporting to PACU Patient identifiers PreOp diagnosis Procedure
Location of incision(s)
Dressing, packing
Drains, catheters, tubes
Stomas, etc
Complications
Allergies and reactions
Medications, fluids, irrigation used
Positioning
Other pertinent issues:
Family
Special requests
Devices
Patient deficits
Rothruck: Pg 269
Anesthesia provider is responsible to stay with patient until PACU RN accepts patient; pain management, pertinent medical/surgical history, etc.

15. References:
AORN. (2015). Guidelines for perioperative practice (2015 ed.). Denver, CO: AORN.
Gawande, A. (2010). The checklist manifesto: How to get things right. New York, NY: Picador.
Phillips. (2007). Berry & Kohn’s operating room technique (11th ed.). St. Louis, MO: Elsevier Mosby.
Rothrock, J. (2011). Care of the patient in surgery (14th ed.). St. Louis, MO: Elsevier Mosby.
Wound classification, OR. (2015). Lippincott procedures. Retrieved from: &s=p