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January 16, 2015

JAMA: Why surgical checklists aren't saving lives

Daily Briefing

Surgical checklists have become standard at most U.S. hospitals, but a new study in JAMA Surgery suggests they don't always lead to improvements in patient safety.

In an editorial accompanying the study, University Health Network surgeon David Urbach writes, "The story of surgical quality improvement has become a saga of high hopes followed by dashed expectations."

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Study: Checklist use does not improve patient safety

For the study, University of Michigan researchers analyzed the outcomes of 64,891 patients who underwent procedures at 29 Michigan hospitals between 2006 and 2010. They found no link between the implementation of the "Keystone Surgery" checklist quality improvement program and improvements in rates of 30-day morality, surgical-site infections, and other complications.

Experts expected Keystone Surgery would be successful because it is based on the 2006 Keystone ICU checklist initiative, which a 2006 NEJM study showed decreased catheter-related bloodstream infections. At the time, an editorial accompanying the study urged hospitals nationwide to adopt checklist efforts—and they did.

However, the checklists seen to be less effective than predicted. The new study aligns with findings from a 2014 study in NEJM, which also failed to find a significant link between checklist use at 100 Ontario hospitals and improvements in patient safety.  

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How to make checklists work in your hospital

The new study's authors say the problem lies with the implementation of checklists, not the tool itself.

To translate checklists into patient safety, health care workers should first identify major issues at their facility and tailor the list to mitigate those specific, recurring problems. Additionally, they should examine the list frequently and update it as needed.

"Successful implementation of clinical interventions depends not only on high-quality evidence but also a receptive environment and facilitation," the authors write, adding, "It is less likely that a single bundle of interventions can successfully be applied across organizations" (Rice, Modern Healthcare, 1/14 [subscription required]).

The takeaway: Authors of a new study in JAMA Surgery say that checklists alone do not improve patient safety; effective implementation plans are required.

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