An eye-catching NEJM study last week suggested that surgical safety checklists might not work. Writing at "The Incidental Economist," Atul Gawande—renowned Brigham and Women's Hospital surgeon, author, and a long-time champion of checklists—explains why they still do.
In his post, Gawande reviews the study, where researchers surveyed 101 hospitals in Canada's Ontario province that introduced surgical checklists between 2008 and 2011. The researchers found no significant drop in complication or mortality rates in the three months after the adoption of checklists.
However, Gawande notes that three months of data and cases that had low mortality risks did not provide a "sufficient sample size to tell if this reduction was significant or not." In a Veterans Affairs (VA) study that ultimately showed an 18% reduction in mortality at 74 VA hospitals, researchers said it took three months for mortality to begin to fall.
Moreover, Gawande notes that the checklists used in the study—which were developed by his research team and the World Health Organization—have been shown to reduce complications and mortality in previous studies at both the small and large scale.
But in the Ontario study, checklist adoption was mandated by the government with no team training, local adaption of the checklist, or adoption tracking. Although the hospitals reported that they were using the checklists, Gawande notes that prior research has shown a major gap between reported checklist compliance and actual compliance.
"It has become clear that implementation takes time," Gawande acknowledges. "My suspicion is that a government mandate without a serious effort to change the culture and practice of surgical teams results in limited change and weak, if any, reduction in mortality."
He concludes, "Perhaps, however, this study will prompt greater attention to a fundamentally important question for health care reform broadly: how you implement an even simple change in systems that reduces errors and mortality – like a checklist" (Gawande, "The Incidental Economist," 3/15).
More from Gawande
From examining hot spots in the New Yorker to prescribing checklists, Atul Gawande has been one of the most prominent figures in health care in recent years. Here's a link to previous Daily Briefing coverage of the influential doctor, with some of our more recent stories pulled out below.