Where surgeons don’t bother with checklists
Ten years ago, checklists for surgeons were all the rage. Inspired by the preflight routines of airline pilots, surgical checklists were shown to prevent tragic errors, reduce infections and save lives.
Dr. Atul Gawande, a Harvardtrained surgeon, championed them in The New Yorker and wrote a book about them, “The Checklist Manifesto: How to Get Things Right.”
A 2-minute, 19-item checklist was eventually endorsed by the World Health Organization, which advocated its use by every hospital in the world. The checklist is even available as a cellphone app from the United Nations Institute for Training and Research.
It includes many simple steps for surgeons who are preparing to operate, some as basic as ascertaining that the right patient is on the table and the incision site correctly marked, and that anesthetics, oxygen and transfusion blood are on hand.
Now that a decade has passed since the WHO’s recommendation, a nonprofit founded by Gawande has surveyed almost 1,500 hospitals in 94 countries to see how often a surgical checklist is used.
Adoption has been spotty, according to the report released Wednesday by the nonprofit, Lifebox, and by Ariadne Labs, a joint venture of the Harvard T.H. Chan School of Public Health and Brigham and Women’s Hospital, both in Boston. (Both institutions seek to improve surgery and anesthesia in poor and middle-income countries.)
In wealthy countries, a list is used in 90 percent of surgeries, the report found. But in poor countries, a checklist is used only about a third of the time.
The study blamed many factors: surgeons who resent the implication that they may make dangerous mistakes, lax enforcement by hospital administrators and the powerlessness of nurses in some cultures.
In poor countries, most surgeries are emergencies, such as cesarean sections, appendectomies or trauma repair after a car crash. Rushed surgical teams are less likely to use a checklist.
In poor countries, there are often failures in support systems intended to ensure the availability of oxygen, blood transfusions and postoperative antibiotics, and sometimes even just clean operating rooms.
When checklists are strictly adhered to, missing even one of those elements can prevent the operation from beginning. Instead, some hospitals just avoid the checklist.
There is enormous room for improvement, the study found.
For example, up to 95 percent of Africa’s population does not have access to safe and affordable surgery, and African patients are twice as likely to die after an operation, compared with the global average, said Dr. Bruce M. Biccard, an anesthesiologist at the University of Cape Town and a leader of the African Surgical Outcomes Study, which produced some of the data used in the new report.
In countries where doctors and nurses do not speak one of the six official languages of the U.N. — Arabic, Chinese, English, French, Russian or Spanish — a checklist is less likely to be used. Also, cultural barriers have hindered its adoption.
The checklist includes requirements that doctors and nurses introduce themselves and confirm that all have the same understanding of how the operation will ideally proceed. But teamwork can be difficult to
introduce, both in traditional cultures based on hierarchy and obedience and in intensely competitive environments like those in U.S. medical schools.
Even hospitals that faithfully used a checklist often adapted it to local circumstances, the report found. Some translated it into Tagalog and Amharic, for example. A West African surgical team added a requirement that the hospital’s generator be working. A Guatemalan team added pain-control medication to the list of requirements.
A decade ago, as a young surgeon in Ethiopia, Dr. Abebe Bekele, the dean of the University of Global Health Equity in Rwanda, tried to introduce the checklist to the hospital where he worked in Addis Ababa, after seeing it when he trained in Seattle.
“No one else was on board,” Bekele, who was a consultant on the Lifebox report, said. His own team used it when he insisted, but not when working with other surgeons, who were usually much older than their nursing staffs.
“I had the momentum but not the wisdom on how to implement it,” he said.
Two years later, however, after studies showed the checklist reduced deaths by 24 percent and major complications by 60 percent, he had more success “by bringing everyone into a single room to discuss and write down the checklist.”
Since then, younger surgeons have become more receptive, Bekele said, and now the checklist is taught in the rapidly expanding medical schools in Ethiopia.
Outside influences can be powerful, the report noted. It singled out the charity Mercy Ships as instrumental in introducing the checklist to Africa. Mercy Ships has a hospital ship that docks for months in various port cities in Africa, performing thousands of surgeries.
At each port of call, it also trains dozens of local medical practitioners.
When the Africa Mercy was docked in Cotonou, Benin, from 2016-17, for example, it sent teams to 36 hospitals to lead workshops in using a surgical checklist.
Before the training, only about 30 percent of surgeries performed incorporated checklists. Afterward, nearly 90 percent did — and compliance was still at 86 percent during followup visits a year later.