Patient Safety in Surgery

Featured article: Adherence to the WHO surgical safety checklist: an observational study in a Swiss academic center.

This prospective observational study was designed to assess the compliance and adherence to the WHO “Safe Surgery Saves Lives” checklist in more than 100 direct observations before, during, and after surgical procedures at a large academic medical center in Switzerland. The authors revealed an impressive consistency in patient identification, preoperative team introduction, and overall compliance to the preoperative “time-out” in 99% to 100% of observed cases. In sharp contrast, the postoperative debriefing was completed in less than one out of five cases, and only 16% of all unexpected critical events that had occurred during surgery were reported during the debriefing phase. The root cause attributed to the poor compliance to postoperative debriefing, which represents the third key pillar of the WHO checklist, was attributed to the unavailability of operating room staff after the procedure. This study confirms a highly concerning low overall rate of adherence to the 19-item WHO surgical safety checklist, more than a decade after its global implementation (Haynes AB et al., N. Engl. J. Med. 2009,360:491-9). These insights from a Swiss academic center have been previously confirmed in a larger scale analysis on 10 hospitals in Colorado which reported a low rate of active physician participation during completion of the WHO checklist (Biffl WL et al., Patient Saf. Surg. 2015,9:5). Arguably, the inadequate compliance to mandatory safety checklists would not be continuously tolerated in other high reliability organizations and high-risk industries outside of the healthcare system. The British writer and physician Sir Arthur Conan Doyle framed the following suitable quote in one of his Sherlock Holmes novels: “I never make exceptions. An exception disproves the rule.” (The Sign of the Four, 1890). It is time for surgeons to step up as unwavering advocates for the vulnerable cohort of patients undergoing surgical procedures, by strictly adhering to established evidence-based patient safety protocols – without making exceptions or excuses.