Where surgeons don’t bother with checklists

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Ten years ago, checklists for surgeons were in fashion. Inspired by the pre-flight routines of airline pilots, it was shown that surgical checklists prevent tragic errors, reduce infections and save lives.

Dr. Atul Gawande, a surgeon trained at Harvard, defended them in The New Yorker and wrote a book about them, “The Checklist Manifesto: How to do things right.”

A checklist of two minutes and 19 items was finally approved by the World Health Organization, which advocated its use in all hospitals in the world. The checklist is even available as an application for cell phones of the United Nations Institute for Vocational Training and Research.

It includes many simple steps for surgeons preparing to operate, some as basic as making sure that the correct patient is at the table and that the incision site is correctly marked, and that anesthetics, oxygen and blood for transfusions are available.

In poor countries, the majority of surgeries are emergencies, such as caesarean sections, appendectomies or trauma repair after a car accident. Rushed surgical teams are less likely to use a checklist.

In poor countries, there are often failures in support systems aimed at ensuring the availability of oxygen, blood transfusions and postoperative antibiotics, and sometimes even in clean operating rooms.

When the checklists are strictly adhered to, missing even one of those elements can prevent the operation from starting. Instead, some hospitals simply avoid the checklist.

There is a huge room for improvement, according to the study.

For example, up to 95 percent of Africa’s population does not have access to safe and affordable surgery, and African patients are twice as likely to die after an operation, compared to the world average, he said. Dr. Bruce M. Biccard, anesthesiologist at the University of Cape Town and leader of the African Surgical Results Study, which produced some of the data used in the new report.

In countries where doctors and nurses do not speak one of the six official languages ​​of the United Nations: Arabic, Chinese, English, French, Russian or Spanish, a checklist is less likely to be used. In addition, cultural barriers have hindered its adoption.

The checklist includes the requirements that doctors and nurses present and confirm that everyone has the same understanding of how the operation will proceed ideally. But teamwork can be difficult to introduce, both in traditional cultures based on hierarchy and obedience and in intensely competitive environments like those of American medical schools.

Even hospitals that faithfully used a checklist often adapted it to local circumstances, according to the report. Some translated it into Tagalog and Amharic, for example. A West African surgical team added the requirement that the hospital generator be running. A Guatemalan team added pain control medications to the list of requirements.

Prior to training, only about 30 percent of surgeries performed checklists incorporated. Then, almost 90 percent did so, and compliance was still 86 percent during follow-up visits a year later.

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