Just as members of a flight crew follow a checklist procedure before takeoff to ensure passenger safety, surgeons are also taking up the torch of protocol when entering the operating room.
While the World Health Organization recommended a general safe surgery checklist in 2008, specialized surgical procedures – such as minimally invasive cardiac surgeries – haven’t had a prescribed standard or universal operating protocol, explained cardiac surgeon Bob Kiaii, a Schulich School of Medicine & Dentistry professor and director of the Division of Cardiac Surgery at London Health Sciences Centre (LHSC).
The general checklist requires ensuring things such as the correct patient is on the operating table, the correct procedure is being prepared and any special health concerns, surrounding things like anesthesia and medications, are addressed, added anesthesiologist colleague Philip Jones, who also teaches at Schulich.
But the general checklist isn’t enough when it comes to specialized procedures.
A cardiac team at LHSC discovered just that. During what was supposed to be a routine procedure, blood started to pool for one patient undergoing heart surgery. The heart was under-filled and surgeons couldn’t immediately locate the source of bleeding. This resulted in a longer surgery for the patient and a post-operative coma.
Out of this, however, sprang a new checklist – outlined in a new paper by Kiaii and Jones, who recently published Lessons from Aviation: The Role of Checklists in Minimally Invasive Cardiac Surgery in the journal Perfusion.
“This checklist was an additional checklist, specific for high-technical requirements of minimally invasive cardiac surgery. It’s in addition to what our hospital has been doing for a number of years now,” Jones said.
“The purpose of our article was to really practice responsible medicine. We know mistakes occur – we don’t name or blame – but we identify a problem. We deal with it up front, and we make sure, most importantly, that it cannot happen again,” he continued.
Human beings are fallible, yes, and highly technical tasks such as cardiac surgeries respond well to a checklist procedure, Jones noted. Their list is specific and targets surgeries of high-risk patients, minimizing risk for error and complication. And while events such as the one at LHSC occur worldwide, they are rarely publicized or discussed, providing no learning opportunities or recommendations for preventative measures.
“We really took it upon ourselves, as a responsibility to share, so nobody else would have the same complication occur,” Jones continued.
As it stands, there are currently few checklists specific to procedures, Kiaii added. And they aren’t necessarily needed across the board. But that doesn’t mean they aren’t needed at all.
“We’re dealing with situations where errors can mean a significant, devastating complication for the patient. It’s a very high-stakes environment. We don’t have standard operating protocol in surgery, as they do in aviation. The reason with this particular case, why an error occurred, is because it was a deviation from what everybody on the team was used to seeing,” Kiaii said.
“So, to avoid this from happening in the future, we made a checklist, which has been extremely successful,” he said, noting their list has now been adopted and modified for specific operations by national and international medical institutions.
Jones and Kiaii aren’t advocating for a proliferation of checklists, just that a protocol be in place for highly technical procedures affecting high-risk patients.
“One of the counter arguments is, there’s such a thing as ‘checklist fatigue,’ and if we are inundated with checklists, we cease to be physicians and thinkers and we’re just robots, who go from one thing to another,” Jones said.
“We don’t want checklists for everything. We want to identify particularly poignant moments in the patient’s care that are amenable to checklists, and for which the significance of a checklist could be critical,” he added.
“It’s our responsibility to share. The only way we can make these procedures better and make a better environment is by sharing this information.”