Safety: We Don't Need Another Checklist

The surgeon had signed the patient's left side and was about to begin surgery, but something didn't feel right to the medical student in the room. "Can we check that one more time?" he asked. "I believe the procedure is supposed to be performed on the other side." It was the right call. The team averted a wrong-sided surgery because the person who occupied the most junior rung on the OR ladder listened to his intuition and felt empowered to speak up.

That event came to light during one of our health system's weekly conferences, during which surgical team members gather to review adverse events and discuss what we could have done differently. Our research team engaged with those conferences in 3 hospitals over 6 months to collect and analyze information about 182 adverse events that occurred during 5,365 procedures. We discovered human error was involved in more than half (106) of them.

Errors linked to communication, teamwork and system protocols were lower than we expected, indicating team-based approaches such as safety checklists have been largely effective in preventing patient harm. But other human errors — lack of attention, recognition mistakes and confirmation bias — are unresolved issues in today's ORs that we need to address, especially when our findings are applied to known national statistics: If human error, as indicated by our study, accounts for half of the adverse events that occur in as many as 5% of the 17 million annual U.S. surgeries, efforts to improve the cognitive performance of surgical teams could prevent about 425,000 adverse events each year.

Instead of adding another to an already almost overwhelming number of checklists designed to prevent the patient harm that continues to occur, we need to focus more on human performance and teach all medical professionals to pay close attention to the voice in the back of their heads that's telling them something doesn't seem right.

Checklists are very effective and worthwhile safety tools, but implementing too many of them can result in burnout and ultimately have your staff checking off boxes of essential steps without engaging in implementation of them. The task becomes onerous, and the checklist provides diminishing returns. We must at some point also be able to rely on our internal checklists to protect patients from harm.

Most facilities have high reliability and structured organization in place, but opportunities for improvement remain. The more levels of protection built into a system of checks and balances, the better, but that doesn't always guarantee errors won't cause patient harm. The Swiss cheese model of medical errors. According to the Swiss cheese model of accident causation, a series of safety barriers have inherent weaknesses and, if the weaknesses align by random chance, errors can reach the patient to cause harm.

Surgical team members' internal checklists must protect patients. We need to help individuals improve their own performances by keeping these cognitive improvement strategies in mind.

• Avoid confirmation bias. It's easy to rush to comply with what you expect to see or hear, instead of what is actually present. For example, we in our research encountered a case where a guide wire stylus that had been inadvertently retained following a procedure was "missed" and not reported on radiology reports. Even though the clinicians caring for the patient subconsciously "saw" the wire, they dismissed their own concerns because they were not validated in official radiology reports. One might assume a lack of attention was to blame for the multiple misses, but this deference to the "official" report well highlights the confirmation bias that can cloud our decision making, and in this case led to the repeated failures to act upon correct and important observations.
• Focus when it counts most. It might be nearly impossible to perform surgery with razor sharp focus for the duration of a procedure, but you can zero in on the task at hand during critical stages (anesthesia induction, technically challenging maneuvers, implant placement and the counting of objects, for example). We can take a cue from commercial aviation on this. Pilots pay attention during every portion of a flight, of course, but are instructed to avoid all distractions and focus with greater intensity on their responsibilities during the critical intervals of takeoff and ascent and descent and landing — the so called "sterile cockpit" when no extraneous conversation is allowed.

• Cognitive training. To improve the cognitive performance of our teams, it is critical that we track the root causes of adverse events and huddle as a group to discuss these errors and how they could have been avoided. One can even use the details of the actual events to run simulation training exercises, which teach the team to review how they can and should respond when similar scenarios occur, as we have done with some of our root cause analyses here at Baylor College of Medicine.

We must at some point also be able to rely on our internal checklists to protect patients.

Exercises such as simulation training can provide physicians and medical staff members with cues about high vulnerability situations and remind them to focus more intently and listen to their inner voice, the one that tells them something doesn't feel quite right. The internal dialogue is ongoing, but without such training, providers may be more prone to ignore it. Teach members of your team to pay attention to their intuition. Tell them to pause when internal alerts sound, self-analyze, speak up and take action if necessary. Cognitive training can also help teams respond to other cognitive distractions, even the errant breaks in routine that inevitably occur in the OR. The training would give surgeons, nurses, techs and anesthesia providers the tools they need to pause, refocus and reengage in the moment after distractions occur. Such lessons could be applied throughout all phases of patient care.

For too long, young physicians and surgeons seem to have been inexorably destined to make the same mistakes made by those who came before them. It's an important exercise to understand why these errors occur and to learn from them, but it may be even more valuable to train providers to recognize what leads to those errors in order to avoid them before they happen. OSM