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  IN THIS Article
 ::  Abstract
 :: Introduction
 ::  Materials and Me...
 :: Results
 :: Discussion
 ::  References

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  Table of Contents     
Year : 2015  |  Volume : 61  |  Issue : 2  |  Page : 92-94

Surgical checklist application and its impact on patient safety in pediatric surgery

1 Department of Paediatric Surgery, Dr. DY Patil University, Navi Mumbai, Maharashtra, India
2 Department of Anaesthesiology, Seth GS Medical College and KEM Hospital, Mumbai, Maharashtra, India
3 Department of Paediatric Surgery, Seth GS Medical College and KEM Hospital, Mumbai, Maharashtra, India

Date of Submission16-Aug-2014
Date of Decision07-Sep-2014
Date of Acceptance25-Oct-2014
Date of Web Publication13-Mar-2015

Correspondence Address:
S N Oak
Department of Paediatric Surgery, Dr. DY Patil University, Navi Mumbai, Maharashtra
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0022-3859.150450

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 :: Abstract 

Background: Surgical care is an essential component of health care of children worldwide. Incidences of congenital anomalies, trauma, cancers and acquired diseases continue to rise and along with that the impact of surgical intervention on public health system also increases. It then becomes essential that the surgical teams make the procedures safe and error proof. The World Health Organization (WHO) has instituted the surgical checklist as a global initiative to improve surgical safety. Aims: To assess the acceptance, application and adherence to the WHO Safe Surgery Checklist in Pediatric Surgery Practice at a university teaching hospital. Materials and Methods: In a prospective study, spanning 2 years, the checklist was implemented for all patients who underwent operative procedures under general anesthesia. The checklist identified three phases of an operation, each corresponding to a specific period in the normal flow of work: Before the induction of anesthesia ("sign in"), before the skin incision ("time out") and before the patient leaves the operating room ("sign out"). In each phase, an anesthesiologist,-"checklist coordinator," confirmed that the anesthesia, surgery and nursing teams have completed the listed tasks before proceeding with the operation and exit. The checklist was used for 3000 consecutive patients. Results: No major perioperative errors were noted. In 54 (1.8%) patients, children had the same names and identical surgical procedure posted on the same operation list. The patient identification tag was missing in four (0.1%) patients. Mention of the side of procedures was missing in 108 (3.6%) cases. In 0.1% (3) of patients there was mix up of the mention of side of operation in the case papers and consent forms. In 78 (2.6%) patients, the consent form was not signed by parents/guardians or the side of the procedure was not quoted. Antibiotic orders were missing in five (0.2%) patients. In 12 (0.4%) cases, immobilization of the patients was suboptimal, which led to displacement of diathermy grounding pad. In 54 (1.8%) patients, the checklist was not used at all. In 76 (2.5%) patients the checklist was found to be incompletely filled. Conclusions: Our study supports the use of the checklist as an essential safety tool and reinforcement of the same. The checklist may act as a valuable prompt to focus the team, to ensure that even the simple things have been cared for.

Keywords: Adverse events, checklist, communication, patient safety

How to cite this article:
Oak S N, Dave N M, Garasia M B, Parelkar S V. Surgical checklist application and its impact on patient safety in pediatric surgery . J Postgrad Med 2015;61:92-4

How to cite this URL:
Oak S N, Dave N M, Garasia M B, Parelkar S V. Surgical checklist application and its impact on patient safety in pediatric surgery . J Postgrad Med [serial online] 2015 [cited 2023 Sep 24];61:92-4. Available from:

 :: Introduction Top

Pediatric Surgery has evolved as a superspeciality in surgical practice and advances in anesthesiology and perioperative intensive care have made complex procedures viable and possible. Technological advances however do not make the practice error proof and human errors attributable to an incorrect attitude, negligence, overconfidence and functioning that is not evidence based tend to precipitate complications. [1] Moreover, young children, and newborns in particular look alike, bear similar names and are unable to communicate their own names and complaints. A safety culture thus needs to evolve and the theatre personnel need to pull together as a team. [2] The present article describes the process of implementation of a surgical checklist with a view to develop a safety culture and attitudinal change at a University teaching hospital in Western India.

 :: Materials and Methods Top

The Department of Pediatric Surgery adopted in 2011, the WHO Surgical Safety Checklist and applied it to 3000 consecutive surgeries that were done under general anaesthesia upto 2013; a 2 year period. The list comprised of three components: Before induction, before surgical incision and the third phase being before the end of surgery and before the patient was wheeled out of operation theatre. The salient points considered were: In the pre-induction phase: Identification of the patient and the consent for the procedure, fasting status confirmation, identification of the side to be operated upon and its marking, pulse oximeter, suction apparatus, availability of medications and airway equipment, defibrillator and patient warming mattress in working condition, medication allergies of the patient, anticipated risks in airway management and anesthesia, availability of blood and blood products. After anesthesia was induced, several checks were done between checklist coordinator and surgeons as well as nursing team. The team members acknowledged each others' roles, identification of the patient, side of the operation and planned procedure, anticipated critical events in surgery. Antibiotic administration was confirmed and its time noted. Diathermy settings and the placement of the grounding pad and the body contact with the patient was confirmed. The patient was strapped and immobilized to the operation table. Removal of metal bangles, ear rings, nose ring, and ornamental waist bands and anklets was confirmed. Necessary radiology imaging was displayed in the theatre. Nursing team reviewed the instruments available and the gauze and mop count before the incision was made. Finally in the third phase, at the end of operation, the gauze or mop count was rechecked, the name of the completed procedure was recorded by the nursing team, the specimen for histopathology was labeled and made ready for dispatch to histopathology and all needles, sponges and instruments were accounted for. If any instrument (e.g., diathermy, heating mattress) had malfunctioned during the performance of the operation, this issue was addressed before the commencement of the next one. The checklist addressed nearly 20 points and was a part of routine theater process.

 :: Results Top

In the period from 2011 to 2013, no major peri-operative errors and events were noted. In 9 (0.3%) of patients events that could be classified as "near missed catastrophe" were observed. In 54 (1.8%) patients, children had the same names and an identical surgical procedure posted on the same operation list on the same day (circumcision for example). In 21 (0.7%) of them, there was an additional procedure of herniotomy to be performed whose mention in the identification tag was missed. The identification tag of the patient itself had come off in 4 patients in the transit toward the operation theatre and that was picked up due to the checklist protocol. Residents and junior staff members had missed out on mentioning the side of procedures like herniotomy, orchidopexy in 108 (3.6%) cases. In 3 (0.1%) of patients who were to undergo major resective procedures like nephrectomy there was mix up regarding the side of the surgery in the case notes consent forms. In 78 (2.6%) of cases the consent form was not signed by parents/guardians nor was the side of the procedure quoted in these forms. Pre-operative antibiotic orders were missing in 5 patients. In 12 (0.4%) cases specifically in laparoscopy, the immobilization of the patients was suboptimal and had led to displacement of grounding pad losing patient contact. The mop and gauze counts were always physically checked and there were no errors there. In 54 (1.8%) patients, we found that the checklist was not used at all. In 76 (2.5%) patients the checklist was found to be incompletely filled. In all these cases, it was the third part of the checklist which was not adhered to.

 :: Discussion Top

The concept of using a checklist in surgical and anesthetic practice was energized by publication of the WHO Surgical Safety Checklist in 2008. [3] It was believed that by routinely checking common safety issues, and by better team communication and dynamics, peri-operative morbidity and mortality could be addressed consistently. The magnitude of improvement demonstrated by the WHO pilot studies has been reconfirmed in some centers. [4] However, some other series have refuted any improvements in the outcome of operative procedures. [5] The present study indicates that in pediatric surgery, surgical checklists, can contribute to improving patient safety. Adherence to the checklist helped in detect instance of human error and instances of equipment malfunction and identify areas that needed strengthening and streamlining.

To many critics, the checklist protocol appears to be a "trivial" practice addressing very "routine" issues. However, minor errors have a multiplicative effect. Introducing surgical checklists is not as straightforward as it seems and requires leadership, flexibility, tenacity and teamwork. [6] The WHO checklist we used also required modification to suit the regional issues with respect to the patient demography. While the senior authors are in a team that has been working together for the last 12 years, junior colleagues are trainees who leave after a stipulated period. Before the checklist was put in practice, there was a detailed discussion with the entire team about the need, the format and inclusion of the components of the check list. We still found that in some instances there was a tendency to do away with the checklists particularly by junior colleagues in the times of an emergency. The junior colleagues in the absence of senior colleagues had a tendency to proceed without adhering to checklist protocols. The challenge therefore is to change the operating theatre culture to reduce minor problems and interruptions that may impact surgical performance and also to improve non-technical skills in the operating theatre. Formal training in non-technical skills conducted in simulator laboratories and class rooms has been shown to improve patient outcomes, but there is often resistance from operating teams. [7] Communication errors are the most common cause of adverse events in healthcare. It is often noted that the information does not reach the right person, or is inaccurate, or issues remain unresolved until they become critical. [8] In the operating theatre, this leads to mistakes, inefficient use of resources, wasted equipment, frustration, poor morale, delays, complications, rise in morbidity and cancelled operations. Patterns of inter-professional communication in theatre follow complex hierarchies, and the communication style of senior members of the team acts as an important role model for trainees. A confrontational or an unjustifiable authoritative style may be mimicked, or it may act as a barrier to a trainee speaking up. [9],[10]

High volume, rapid turnover departments have demonstrated that minor problems, distractions, or equipment problems were associated with increased operating time and reduced operative performance. [11] Literature also supports the view, that not only technical skills, but also the behavioral patterns and non-technical skills of the surgeon and anesthesiologist (leadership, teamwork, problem-solving, decision-making, and situation awareness), that affect surgical outcomes have got positively influenced by the checklist protocol. [12],[13]

A limitation of the present study is that the outcome may have been influenced by an observer bias. Using the checklist would also cause an additional anxiety for the adolescent awake patient. Concerns were often voiced that the checklist may be difficult to use in urgent or emergency situations. In summary. our study supports the use of the surgical checklist as an essential safety tool. Effective implementation however would require training, coaching, and a change in safety attitude, with routine measurement and regular feedback of outcomes.

Note: The work presented in this paper was carried out at the Seth GS Medical College & KEM Hospital, Mumbai.

 :: References Top

Gawande AA, Thomas EJ, Zinner MJ, Brennan TA. The incidence and nature of surgical adverse events in Colorado and Utah in 1992. Surgery 1999;126:66-75.  Back to cited text no. 1
van Klei WA, Hoff R, van Aarnhem EE, Simmermacher RK, Regli LP, Kappen TH, et al. Effects of the introduction of the WHO 'Surgical Safety Checklist' on in-hospital mortality: A cohort study. Ann Surg 2012;255:44-49.  Back to cited text no. 2
Walker IA, Reshamwalla S, Wilson IH. Surgical safety checklists: Do they improve outcomes? Br J Anaesth 2012;109:47-54.  Back to cited text no. 3
Department of Health. High Quality Care for All. NHS Next Stage Review Final Report. Available from: [Last accessed on 2014 Jul 22].  Back to cited text no. 4
Urbach DR, Govindarajan A, Saskin R, Wilton AS, Baxter NN. Introduction of surgical safety checklists in Ontario, Canada. N Engl J Med 2014;370:1029-38.  Back to cited text no. 5
World Alliance for Patient Safety. WHO Surgical Safety Checklist and Implementation Manual. Available from: [Last accessed on 2014 Jul 22].  Back to cited text no. 6
Joy BF, Elliott E, Hardy C, Sullivan C, Backer CL, Kane JM. Standardized multidisciplinary protocol improves handover of cardiac surgery patients to the intensive care unit. Pediatr Crit Care Med 2011;12:304-8.   Back to cited text no. 7
Zavalkoff SR, Razack SI, Lavoie J, Dancea AB. Handover after pediatric heart surgery: A simple tool improves information exchange. Pediatr Crit Care Med 2011;12:309-13.  Back to cited text no. 8
Craig R, Moxey L, Young D, Spenceley NS, Davidson MG. Strengthening handover communication in pediatric cardiac intensive care. Paediatr Anaesth 2012;22:393-9.   Back to cited text no. 9
Lingard L, Reznick R, Espin S, Regehr G, DeVito I. Team communications in the operating room: Talk patterns, sites of tension, and implications for novices. Acad Med 2002;77:232-7.  Back to cited text no. 10
Pronovost PJ, Goeschel CA, Colantuoni E, Watson S, Lubomski LH, Berenholtz SM, et al. Sustaining reductions in catheter related bloodstream infections in Michigan intensive care units: Observational study. BMJ 2010;340:c309.   Back to cited text no. 11
Brennan TA, Leape LL, Laird NM, Hebert L, Localio AR, Lawthers AG, et al. Incidence of adverse events on hospitalized patients. Results of the Harvard Medical Practice Study I. N Engl J Med 1991;324:370-6.   Back to cited text no. 12
Catchpole KR, de Leval MR, McEwan A, Pigott N, Elliott MJ, McQuillan A, et al. Patient handover from surgery to intensive care: Using Formula 1 pit-stop and aviation models to improve safety and quality. Paediatr Anaesth 2007;17:470-8.  Back to cited text no. 13

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