How’s your checklist working?

Wrong site surgery and other sentinel events reported to The Joint Commission were up in 2021, according to The Joint Commission’s recent Sentinel Event Data update.

We know a standardized surgical safety checklist used by an engaged team is one of the most important communication tools a surgical team can use to catch surgery-related sentinel events before they happen.

We also know that any tool used in surgery needs auditing for compliance and regular updating to ensure it remains relevant, stresses Surgical Safety Checklist champion Elizabeth Kingsbury, MS, RN, CNOR, perioperative nurse at Boston Children’s Hospital (BCH). She led BCH in implementing their first version of the checklist in 2009, worked with Atul Gawande’s checklist team at Ariadne Labs in Boston, and helped train and implement a Surgical Safety Checklist with the South Carolina Hospital Association in 2013.

While a Surgical Safety Checklist is an invaluable communication tool to protect patients from preventable harms, she says “a one-and-done checklist that isn’t reviewed and updated periodically could be putting patients at risk.” That’s why she’s a big believer in continually coaching teams to enhance checklist compliance and auditing checklist compliance to use these data for updating the checklist as needed.

Kingsbury and her team recently updated their fourth iteration of their Surgical Safety Checklist at BCH, and they are presenting a poster on this work next week at AORN 2022 Global Surgical Conference & Expo.

Periop Today talked to Kingsbury ahead of the conference to ask a few questions about how she and her team approached this latest Surgical Safety Checklist update.

Periop Today: Why did you and your team decide it was time to revisit your Surgical Safety checklist again?

Kingsbury: Our teams were finding it difficult to come to a “hard stop” and we felt it was time to re-invigorate how we run our Surgical Safety Checklist to enhance checklist standardization. In our last version of the checklist, we had the surgeons lead the checklist, and through our checklist auditing process, we found it was not always used consistently. Our checklist update team was multidisciplinary, so we had the voice of surgeons, nurses, and anesthesiologists to give a thoughtful review of the checklist content and the way it was intended to be used.

Periop Today: How did the team work together to update your Surgical Safety Checklist?

Kingsbury: We established smaller teams to work on each section of the checklist and bring suggestions back to the group. Through group discussion we decided to empower the circulating nurse to lead the checklist, which has been a big change in practice. We capitalized on fewer operative procedures during the pandemic to test the proposed changes to the checklist in the OR before settling on a final version and we used the extra time for hands-on training with circulating nurses to practice how to lead the checklist as intended.

Periop Today: Can you describe a few significant changes this team made to the latest version of your checklist?

Kingsbury: First we modified all the elements of the checklist to a question format; now the circulator asks the OR team questions and the surgeon, anesthesiologists and scrub all answer their part of the checklist. Our chief of anesthesia wanted to implement a “Distraction Free Zone” during induction of anesthesia and use the “Sign In” aspect of the checklist for this new practice. Additionally, we updated the fire risk assessment score to a 4-point system, and added questions regarding implants (type, size, outdate, availability), and expected blood loss with a new blood loss algorithm.

Periop Today: How is the team auditing the latest checklist version and what are these compliance data showing?

Kingsbury: Auditing is done by observing the checklist usage in the OR. In-the-moment coaching of teams when the checklist is used incorrectly is a great way to foster improvement in a non-punitive way. We have always collected data on Time Out, but I developed a more comprehensive audit tool to use after implementing the new checklist and we have improved consistent safety actions in three important areas, with site marking compliance at 100%, updated fire assessment score compliance at 98.6%, and circulator use of the checklist as a standard reference tool at 97.2%. We have seen great improvement overall with how our checklist is used.