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Pairing checklists with teamwork improves patient outcomes

Adverse events following high-risk surgeries decreased by more than 15 percentage points after health professionals used a checklist and worked as a team.

By Carolyne Krupa — Posted Jan. 7, 2013

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Surgical teams can decrease expensive postoperative complications by learning to work together better and using a surgical checklist, according to a study in the December Journal of the American College of Surgeons.

Researchers compared data on nearly 2,400 high-risk surgical procedures and found that using a checklist developed by the Assn. of Perioperative Registered Nurses — coupled with training in how best to implement the checklist and work as a team — significantly reduced adverse events.

Data used in the study were evaluated between December 2010 and March 2011 for the American College of Surgeons' National Surgical Quality Improvement Program. They included procedures on adults that used general, spinal or epidural anesthesia, but not traumatic injuries or organ transplants. Researchers analyzed 2,079 control cases, 246 cases with team training but no checklist and 73 cases with the checklist and team training.

For the training, surgical teams participated in three 60-minute sessions covering subjects such as how to use the comprehensive surgery checklist and how to communicate and work together under high pressure.

Researchers added the training component to ensure participants would get the maximum benefit from the checklist, said Lindsay A. Bliss, MD, lead study author and a second-year general surgery resident at the University of Connecticut School of Medicine.

“As opposed to just giving them a checklist and telling them to check a row of boxes, we wanted to give individuals using it the best tools to make it successful,” Dr. Bliss said.

Thirty-day morbidity figures showed a significant drop in adverse event rates from 23.6% for historical control cases to 15.9% in cases with only team training and 8.2% in cases with checklist use and team training.

The key is reducing the traditional hierarchy and intimidation of the surgery team. It is important that each member feels comfortable speaking up to address problems that arise during a procedure, Dr. Bliss said.

“Traditionally, the surgeon is the captain of the ship. You lose out on the experience and expertise of other people in the room,” she said.

The list serves as an inexpensive tool to reduce health care costs and improve patient outcomes, the study said. Subjects completed an average of 97.26% of the checklist columns during each procedure. “Training allows OR personnel to use the checklist as a tool to facilitate communication,” the study said.

The findings demonstrate the importance of fostering an atmosphere of teamwork in which health professionals can work together and feel empowered to advocate for the patient without fear of retribution, Dr. Bliss said.

“We need to create a culture of working in a team,” she said. “Anything occurring in a silo is not going to be the best for the patient.”

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