Advertisement
Review Article| Volume 30, ISSUE 1, P155-169, 2012

Checklists, Briefings, and Operating Room Safety

      Preoperative checklists have been shown to be highly effective in improving compliance with safety steps and reducing perioperative morbidity and mortality.

      Keywords

      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to Advances in Anesthesia
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Reason J.
        Human error: models and management.
        BMJ. 2000; 320: 768-770
        • Reason J.
        Human error.
        Cambridge University Press, New York1990 (p. 234–41)
      1. John Schamel. How the Pilot's Checklist Came About.http://www.atchistory.org/History/checklst.htm. Accessed 5 September, 2012.

        • Karl R.
        Briefings, checklists, geese, and surgical safety.
        Ann Surg Oncol. 2010; 17: 8-11
        • Winters B.D.
        • Gurses A.P.
        • Lehmann H.
        • et al.
        Clinical review. Checklists: translating evidence into practice.
        Crit Care. 2009; 13: 210
        • Boorman D.J.
        Today's electronic checklists reduce likelihood of crew errors and help prevent mishaps.
        ICAO J. 2001; 1: 17-22
        • Hales B.
        • Terblanche M.
        • Fowler R.
        • et al.
        Development of medical checklists for improved quality of patient care.
        Int J Qual Health Care. 2008; 20: 22-30
        • Leape L.L.
        Error in medicine.
        JAMA. 1994; 272: 1851-1857
        • Kohn L.L.
        • Corrigan J.M.
        • Donaldson M.S.
        To err is human.
        Institute of Medicine, National Academy Press, Washington (DC)1999
        • Bohnen J.M.
        • Lingard L.
        Error and surgery: can we do better?.
        Can J Surg. 2003; 46: 327-329
        • Vincent C.
        • Moorthy K.
        • Sarker S.K.
        • et al.
        Systems approaches to surgical quality and safety: from concept to measurement.
        Ann Surg. 2004; 239: 475-482
        • March M.G.
        • Crowley J.J.
        An evaluation of anesthesiologists' present checkout methods and the validity of the FDA checklist.
        Anesthesiology. 1991; 75: 724-729
        • Arbous M.S.
        • Meursing A.E.
        • van Kleef J.W.
        • et al.
        Impact of anesthesia management characteristics on severe morbidity and mortality.
        Anesthesiology. 2005; 102: 257-268
        • Wolff A.M.
        • Taylor S.A.
        • McCabe J.F.
        Using checklists and reminders in clinical pathways to improve hospital inpatient care.
        Med J Aust. 2004; 181: 428-431
        • Young G.B.
        • Frewen T.
        • Barr H.W.
        • et al.
        Checklist for diagnosis of brain death.
        Can J Neurol Sci. 1991; 18: 104
        • Schectman J.M.
        • Schorling J.B.
        • Nadkarni M.M.
        • et al.
        The effect of physician feedback and an action checklist on diabetes care measures.
        Am J Med Qual. 2004; 19: 207-213
        • Hall R.I.
        • Rocker G.M.
        • Murray D.
        Simple changes can improve conduct of end-of-life care in the intensive care unit.
        Can J Anaesth. 2004; 51: 631-636
        • Pronovost P.
        • Berenholtz S.
        • Dorman T.
        • et al.
        Improving communication in the ICU using daily goals.
        J Crit Care. 2003; 18: 71-75
        • O'Grady N.P.
        • Alexander M.
        • Dellinger E.P.
        • et al.
        Guidelines for the prevention of intravascular catheter-related infections.
        MMWR Recomm Rep. 2002; 51: 1-29
        • Berenholtz S.M.
        • Pronovost P.J.
        • Lipsett P.A.
        • et al.
        Eliminating catheter-related bloodstream infections in the intensive care unit.
        Crit Care Med. 2004; 32: 2014-2020
        • Pronovost P.
        • Needham D.
        • Berenholtz S.
        • et al.
        An intervention to decrease catheter-related bloodstream infections in the ICU.
        N Engl J Med. 2006; 355: 2725-2732
        • DeFontes J.
        Preoperative safety briefing project.
        Perm J. 2004; 8: 21-27
        • Makary M.A.
        • Holzmueller C.G.
        • Thompson D.
        • et al.
        Operating room briefings: working on the same page.
        Jt Comm J Qual Patient Saf. 2006; 32: 351-355
        • Makary M.A.
        • Mukherjee A.
        • Sexton J.B.
        • et al.
        Operating room briefings and wrong-site surgery.
        J Am Coll Surg. 2007; 204: 236-243
        • Nundy S.
        • Mukherjee A.
        • Sexton J.B.
        • et al.
        Impact of preoperative briefings on operating room delays: a preliminary report.
        Arch Surg. 2008; 143: 1068-1072
        • Lingard L.
        • Espin S.
        • Rubin B.
        • et al.
        Getting teams to talk: development and pilot implementation of a checklist to promote interprofessional communication in the OR.
        Qual Saf Health Care. 2005; 14: 340-346
        • Lingard L.
        • Regehr G.
        • Orser B.
        • et al.
        Evaluation of a preoperative checklist and team briefing among surgeons, nurses, and anesthesiologists to reduce failures in communication.
        Arch Surg. 2008; 143: 12-17
        • Lingard L.
        • Regehr G.
        • Cartmill C.
        • et al.
        Evaluation of a preoperative team briefing: a new communication routine results in improved clinical practice.
        BMJ Qual Saf. 2011; 20: 475-482
      2. WHO, SSSL_Brochure_finalJun08.pdf, WHO.int; http://www.who.int/patientsafety/safesurgery/knowledge_base/SSSL_Brochure_finalJun08.pdf, 2008. Accessed 5 September, 2012.

      3. WHO, Safe Surgery Checklist, WHO.int, http://www.who.int/patientsafety/safesurgery/tools_resources/SSSL_Checklist_finalJun08.pdf, 2008. Accessed 5 September, 2012.

        • Gawande A.
        The checklist manifesto.
        Henry Holt & Co, New York2009 (p. 114–35)
        • Haynes A.B.
        • Weiser T.G.
        • Berry W.R.
        • et al.
        • Safe Surgery Saves Lives Study Group
        A surgical safety checklist to reduce morbidity and mortality in a global population.
        N Engl J Med. 2009; 360: 491-499
        • Weiser T.G.
        • Haynes A.B.
        • Dziekan G.
        • et al.
        • Safe Surgery Saves Lives Investigators and Study Group
        Effect of a 19-item surgical safety checklist during urgent operations in a global patient population.
        Ann Surg. 2010; 251: 976-980
      4. WHO Safe Surgery Saves Lives Newsletter, April, 2010, WHO.int; http://www.safesurg.org/uploads/1/0/9/0/1090835/april_newsletter.pdf. Accessed 5 September, 2012.

        • de Vries E.N.
        • Prins H.A.
        • Crolla R.M.
        • et al.
        • SURPASS Collaborative Group
        Effect of a comprehensive surgical safety system on patient outcomes.
        N Engl J Med. 2010; 363: 1928-1937
        • Neily J.
        • Mills P.D.
        • Young-Xu Y.
        • et al.
        Association between implementation of a medical team training program and surgical mortality.
        JAMA. 2010; 304: 1693-1700
        • Wolf F.A.
        • Way L.W.
        • Stewart L.
        The efficacy of medical team training: improved team performance and decreased operating room delays: a detailed analysis of 4863 cases.
        Ann Surg. 2010; 252: 477-483
        • Paull D.E.
        • Mazzia L.M.
        • Wood S.D.
        • et al.
        Briefing guide study: preoperative briefing and postoperative debriefing checklists in the Veterans Health Administration medical team-training program.
        Am J Surg. 2010; 200: 620-623
        • France D.J.
        • Leming-Lee S.
        • Jackson T.
        • et al.
        An observational analysis of surgical team compliance with perioperative safety practices after crew resource management training.
        Am J Surg. 2008; 195: 546-553
        • Halverson A.L.
        • Andersson J.L.
        • Anderson K.
        • et al.
        Surgical team training: the Northwestern Memorial Hospital experience.
        Arch Surg. 2009; 144: 107-112
        • Conley D.M.
        • Singer S.J.
        • Edmondson L.
        • et al.
        Effective surgical safety checklist implementation.
        J Am Coll Surg. 2011; 212: 873-879
        • Helmreich R.L.
        • Merritt A.C.
        • Wilhelm J.A.
        The evolution of Crew Resource Management training in commercial aviation.
        Int J Aviat Psychol. 1999; 9: 19-32
        • Leape L.L.
        New world of patient safety: 23rd Annual Samuel Jason Mixter lecture.
        Arch Surg. 2009; 144: 394-398
        • Amalberti R.
        • Auroy Y.
        • Berwick D.
        • et al.
        Five system barriers to achieving ultrasafe health care.
        Ann Intern Med. 2005; 142: 756-764
        • Kennedy T.J.
        • Regehr G.
        • Baker G.R.
        • et al.
        It's a cultural expectation. The pressure on medical trainees to work independently in clinical practice.
        Med Educ. 2009; 43: 645-653
        • Cabana M.D.
        • Rand C.S.
        • Powe N.R.
        • et al.
        Why don't physicians follow clinical practice guidelines? A framework for improvement.
        JAMA. 1999; 282: 1458-1465
        • Fourcade A.
        • Blache J.L.
        • Grenier C.
        • et al.
        Barriers to staff adoption of a surgical safety checklist.
        BMJ Qual Saf. 2012; 21: 191-197
        • Vats A.
        • Vincent C.A.
        • Nagpal K.
        • et al.
        Practical challenges of introducing WHO surgical checklist: UK pilot experience.
        BMJ. 2010; 340: b5433
        • Khoshbin A.
        • Lingard L.
        • Wright J.G.
        Evaluation of preoperative and perioperative operating room briefings at the Hospital for Sick Children.
        Can J Surg. 2009; 52: 309-315
        • Sax H.C.
        • Browne P.
        • Mayewski R.J.
        • et al.
        Can aviation-based team training elicit sustainable behavioral change?.
        Arch Surg. 2009; 144: 1133-1137
        • ElBardissi A.W.
        • Wiegmann D.A.
        • Dearani J.A.
        • et al.
        Application of the human factors analysis and classification system methodology to the cardiovascular surgery operating room.
        Ann Thorac Surg. 2007; 83: 1412-1418
        • Pronovost P.J.
        • Freischlag J.A.
        Improving teamwork to reduce surgical mortality.
        JAMA. 2010; 304: 1721-1722
        • Lee T.H.
        Turning doctors into leaders.
        Harv Bus Rev. 2010; 88: 50-58
        • Zohar E.
        • Noga Y.
        • Davidson E.
        • et al.
        Perioperative patient safety: correct patient, correct surgery, correct side. A multifaceted, cross-organizational, interventional study.
        Anesth Analg. 2007; 105: 443-447
        • Mazzocco K.
        • Petitti D.B.
        • Fong K.T.
        • et al.
        Surgical team behaviors and patient outcomes.
        Am J Surg. 2009; 197: 678-685
        • Makary M.A.
        • Sexton J.B.
        • Freischlag J.A.
        • et al.
        Patient safety in surgery.
        Ann Surg. 2006; 243: 628-632
        • Makary M.A.
        • Sexton J.B.
        • Freischlag J.A.
        • et al.
        Operating room teamwork among physicians and nurses: teamwork in the eye of the beholder.
        J Am Coll Surg. 2006; 202: 746-752
        • Altpeter T.
        • Luckhardt K.
        • Lewis J.N.
        • et al.
        Expanded surgical time out: a key to real-time data collection and quality improvement.
        J Am Coll Surg. 2007; 204: 527-532
        • de Korne D.F.
        • van Wijngaarden J.D.
        • Hiddema U.F.
        • et al.
        Diffusing aviation innovations in a hospital in The Netherlands.
        Jt Comm J Qual Patient Saf. 2010; 36: 339-347
        • Tobin S.N.
        • Campbell D.A.
        • Boyce N.W.
        Durability of response to a targeted intervention to modify clinician transfusion practices in a major teaching hospital.
        Med J Aust. 2001; 174: 445-448
        • Johnston G.
        • Ekert L.
        • Pally E.
        Surgical site signing and “time out”: issues of compliance or complacence.
        J Bone Joint Surg Am. 2009; 91: 2577-2580
        • Ziewacz J.E.
        • Arriaga A.F.
        • Bader A.M.
        • et al.
        Crisis checklists for the operating room: development and pilot testing.
        J Am Coll Surg. 2011; 213: 212-217
        • Neal J.M.
        • Hsiung R.L.
        • Mulroy M.F.
        • et al.
        ASRA checklist improves trainee performance during a simulated episode of local anesthetic systemic toxicity.
        Reg Anesth Pain Med. 2012; 37: 8-15