1. Fasten your seatbelts: the use of checklists
Mara Berman, MSN, MBA, RN, CNOR
Department of Surgery
South Miami Hospital

2. disclosures

3. Course objectives
Recognize the importance of the implementation of a Culture of Safety
Describe the importance of checklists within the healthcare environment
Differentiate between the various phases of the Universal Protocol
Identify the barriers to checklists

4. Culture of safety
Goal: Lessen harm to patients & providers through system effectiveness & individual performance
Professional Culture:
Promotes effective & efficient communication
Hierarchial status & personal preferences put aside
Patient care is a priority
Always do the right thing
Everyone works together to achieve the same goal – optimal patient care and outcomes.
Effective surgical team communication is vital to creating a reliable culture of safety in ORs. In 2000, the Institute of Medicine released its sentinel event report: “To Err is Human: Building a Safer Health System”. It was revealed: at least 44,000 people, and perhaps as many as 98,000 die in hospitals each year as a result of medical errors that could have been prevented. High error rates are reported in ICUs, ORs, and EDs. Today the statistics have risen to 210,000 and 440,000.
Development of a “Surgical Conscience”.

5. Culture of safety Obstacles:
Complex & risk-prone systems that produce unintended consequences
Tolerance of stylistic practices & lack of standardization
Fear of punishment which inhibits reporting
Lack of ownership for patient safety
Blame-free environment should be established. Find solutions to issues through Root Cause Analyses or Failure Mode Effect Analysis (identifying all possible failures in a design or service).
Sentinel events continue to occur in the U.S. The Joint Commission recently reported that the most frequently identified root causes of sentinel events are human factors, leadership, and communication.
Institute of Medicine has recommended that healthcare providers implement systems to ensure safety practices at the delivery level.

6. Development of checklist
Began in the 1930s in the aviation industry
Boeing developed pilot’s checklist
New planes went on to fly 1.8 million times without incident
New planes were being developed with complicated flight instructions, that were too complex to be left to pilot memory.
(Spruce, 2014)

7. The checklist manifesto
Atul Gawande, 2009
50 million surgeries performed every year
150,000 patients die each year undergoing surgery
Atul Gawande authored “The Checklist Manifesto”, a groundbreaking look at the fact that healthcare and medicine have become so complex and specialized, they are difficult for humans to master.
The Checklist Manifesto discusses the importance of organization & pre-planning (such as through checklists) in both medicine and the larger world.
Dr. Gawande is an American surgeon, writer, & public health researcher. He is also the director of the World Health Organization’s Global Patient Safety Challenge.
He believes that many surgical deaths are avoidable & preventable through the use of surgical checklists.
(Spruce, 2014)

8. Surgical checklists Created by: The Joint Commission
World Health Organization
Surgical Patient Safety System
Association of periOperative Registered Nurses
Originally developed as an effective & economical tool to decrease morbidity & mortality n the surgical setting.
Surgical checklists are utilized worldwide. Many emulate the WHO checklist, & some have been somewhat modified to meet the needs of the particular institution.
The WHO Surgical Safety Checklist has been shown to reduce the rate of complications, including death; as well as improving surgical team communication, teamwork climate, safety climate, and surgical outcomes.

9. Purpose of checklists Promotes: Information exchange Team cohesion
Error reduction
Surgical safety checklists are associated with a decrease in surgical complications, an increase in detecting potential safety hazards, & an improvement in communication among team members.
Part of Universal Protocol – Fire Risk Assessment

10. Purpose of checklists Reduce the number of communication failures
Promote proactive & collaborative team communication
Reduce unexpected delays in the OR
Decrease the frequency of communication breakdowns that lead to delays
Reduce intraoperative incidents
Most failures attributed to lack of communication.

11. Consists of 3 phases: Sign In, Time Out, Sign Out
(World Health Organization, 2016)

12. Universal protocol
The Joint Commission requested its implementation by July 1, 2004
Relationship to wrong site, wrong procedure, & wrong person surgery
Three phases:
Performing a preoperative verification
Marking the surgical site
Taking a time out (verify procedure, patient, & site)
Wrong site surgery continues to be a significant problem.

13. Sign in Patient has confirmed: Identity Site Procedure Consent
Site marked/Not applicable
Notation of pertinent patient history (i.e. allergies, risks)
Include all factors to be addressed prior to surgery

14. Sign in Inclusive information: Appropriate consents signed
Blood availability
Advanced directives
History & Physical
Pertinent labs & X-rays
Pre-op shower
Beta blockers
Antiembolic prophylaxis
Dentures, hearing aids, glasses, prosthesis, jewelry, piercings
Significant information. Includes Core Measures.

15. Time out
Confirm all team members have introduced themselves by name & role
Surgical team confirms: patient, site, & procedure
Anticipated critical events
Antibiotic prophylaxis – within 60 minutes of incision
Multidisciplinary team approach.
Anesthesia pause.
All Stop – Active participation. Read from checklist - Do not rely on memory.
Surgeon reviews – what are critical or unexpected steps, operative duration, anticipated blood loss.
Anesthesia reviews – are there any patient-specific concerns.
Nurse reviews – has sterility been confirmed, equipment issues, or any concerns. Essential imaging displayed.

16. Time out / fire risk assessment
(Association of periOperative Registered Nurses, 2016)

17. Sign out Debriefing: Nurse verbally confirms with team:
Name of procedure recorded
Instrument, sponge, & sharp counts are correct
Specimen labeling
Equipment problems to be addressed
Surgeon, anesthesia provider, & nurse review key concerns for recovery & patient management.

18. Problems with checklists
Cumbersome (too many)
Completed rotely
Lack of attention
Failure to understand & address complex challenges in patient safety & quality improvement
Checklists do not always reflect an understanding of the problems needing to be solved, how best to solve them, or the intricacies surrounding the implementation of the tool.

19. summary
Checklists are important tools to promote effective & efficient communication amongst healthcare providers.
Checklists can positively contribute to the development of a Culture of Safety.
Checklists/Universal Protocol are utilized worldwide.
It is important to understand the reasons for the implementation of the checklist; i.e. will it resolve an issue.

20. References
Association of periOperative Registered Nurses. (2016). Fire Risk Assessment Tool. Retrieved from
Barnsteiner, J. (2011). Teaching the culture of safety. OJIN: The Online Journal of Issues in Nursing, 16(3),
Cabral, R. A., Eggenberger, T., Keller, K., Gallison, B.S., & Newman, D. (2016). Use of a surgical safety checklist to improve team communication. AORN Journal, 104(3),

21. references
Carney, B. T., West, P., Neily, J., Mills, P. D., & Bagian, J. P. (2009). Differences in nurse and surgeon perceptions of teamwork: Implications for use of a briefing checklist in the OR. AORN Journal, 91(6),
Catchpole, K., & Russ, S. (2015). The problem with checklists. BMJ Quality & Safety, 24(9),
Conrardy, J. A., Brenek, B., & Myers, S. (2010). Determining the state of knowledge for implementing the universal protocol recommendations: An integrative review of the literature. AORN Journal, 92(2),

22. references
McDowell, D. S., & McComb, S. A. (2014). Safety checklist briefings: A systematic review of the literature. AORN Journal, 99(1),
Spruce, L. (2014). Back to basics: Implementing the surgical checklist. AORN Journal, 100(5),
World Health Organization. (2016). WHO Surgical Safety Checklist. Retrieved from