Editorial - WHO Surgical Safety Checklist

Parulekar SV

Healthcare is broadly speaking preventive and curative. Therapeutic measures are medical surgical and medical. Both of these methods are likely to create complications through negligence. About 50% of the surgical cases which caused harm to the patient by surgery were due to preventable actions or unsafe surgical practices. Hence WHO created a document called 'WHO Surgical Safety Checklist'. Working groups of international specialists reviewed the literature and the experiences of clinicians, the results of which were used to develop this checklist by WHO in collaboration with the Harvard School of Public Health. Global implementation of this 19-item tool was recommended by WHO. The job done by WHO was indeed commendable. A good surgical team always has a checklist in mind, and it was so even before WHO brought out the document in 2009. But all teams or team members not always so careful, and a point or two can be left out. A checklist prevents such a mishap. Hence I am all in favor of a checklist. Our readers will remember that we have devoted an entire issue to checklists in department of Obstetrics and Gynecology of K E M Hospital, Mumbai, India. A surgical checklist was also included in it.

A critical review of the WHO checklist is in order nine years after the original document was published. There are three sections in the checklist - before induction of anesthesia, before skin incision, and before the patient leaves the operation theater (OT).

As per the checklist in its existing form, before induction of anesthesia, at least a nurse and anesthetist have to see that the patient confirms his/her identity, procedure, surgical site and consent. Actually the surgeon has to be the principal person, and all three of them have to be a part of the procedure. Marking the site is a little superfluous, as an error can be committed at this stage just as the stage of operating without prior marking. Check of anesthesia machine should also include disposable kits, drugs and anesthetic gases. Checking functionality of pulse oximeter alone is not adequate. All equipment needs to be checked, including mulipara monitors, electrocautery, special surgical instruments (based on nature of the operation, such as endoscopes, monitors, microscopes, and suction units). The estimation of expected blood loss is always a matter of dispute between anesthetists and surgeons when it has already occurred. Preoperative estimate needs to be determined during the planning stage of the operation and not before induction of anesthesia. It should be based on statistics and not opinion of the surgical team. The checklist should not be to see if the estimated figure is entered in the case paper, but to confirm that blood compatible with the patient's blood is available when the estimated blood loss is more than 500 ml.

Prior to making the skin incision, the checklist states all team members have introduced themselves by name and role. This is perhaps necessary when OT slots are given by prior booking to different teams. But it is superfluous when the team is fixed at least for the day, when all team members know one another. Confirming the patient's name at this stage is bordering on ridiculous, as anesthesia should never been given unless the patient has been identified first. Discovering that a wrong person lies anesthetized on the operation table implies that it is still OK to back out. This stage should never be reached.
Medicolegal negligence lawsuits cannot be prevented even if the patient is taken out of anesthesia. Checking how long the operation will last needs to be checked before administration of anesthesia, so that the anesthesiologist can plan accordingly. Checking it afetr induction of anesthesia serves no purpose. A nurse checking that all equipment required is available, properly functional and sterile at this stage is too late. She has to do it before the patient enters the OT. Recommendations for before patient leaves operating room also leave much to be desired. The nurse verbally confirming the name of the procedure after is complete does not help anyone. God forbid, but if it discovered at this stage that a wrong procedure has been performed, imagine the consequences. Completion of instrument, sponge and needle counts needs to be done before the patient's operative area is closed, such as the abdomen and thorax. If anything is found missing after closure of the surgical incision, one has to open the patient again. That not only increases the patient's morbidity but also will lead to litigation for negligence, which the surgical team will lose.

I hope WHO notes the need for a newer version of the original checklist. I also hope that it involves in this venture more surgeons and anesthetists rather than preventive medicine or public health specialists.