W.H.O. Issues a Checklist to Make Operations Safer
By LAWRENCE K. ALTMAN
The World Health Organization issued its first guidelines on Tuesday aimed at reducing complications and deaths from the rising numbers of operations now being performed.
The guidelines are a list of simple safety checks that the health organization said could halve the rate of surgical complications. The list is intended to improve anesthetic safety practices, avoid infections and improve communication among members of surgical teams.
For example, one guideline calls for all members of the masked surgical team to identify themselves and their roles and ask simple questions like, â€œDoes everyone agree that this is Patient X, undergoing a hernia repair?â€?
Other recommendations call for marking the correct site for surgery to avoid operating on the wrong patient or performing the wrong procedure; giving an antibiotic within 60 minutes of making an incision, to reduce infections; checking for allergies to drugs; inserting two intravenous lines for operations involving substantial blood loss; and counting sponges and needles to ensure that none are left in a patient.
Dr. E. Patchen Dellinger, vice chairman of surgery at the University of Washington, which took part in the W.H.O. research, said that when the checklist was discussed with nonmedical people, â€œthe most common reaction is the question: â€˜You mean you havenâ€™t been doing this all along?â€™Â â€?
The surgical guidelines grew out of a similar checklist aimed at reducing infections in hospitals. The infection guidelines were developed by Dr. Peter J. Pronovost of Johns Hopkins University, who borrowed the idea from the aviation industry, said Dr. Atul Gawande, of the Harvard School of Public Health.
Dr. Gawande and his team at Harvard had been asked by the W.H.O. to develop a method to reduce surgical deaths, and he said they used the infection guidelines as a model.
Three countries â€” Britain, Ireland and Jordan â€” have said they will put the surgery guidelines in force in all hospitals, Dr. Gawande said. Professional groups endorsing checklists include the American College of Surgeons, the American Society of Anesthesiology and the Association of Perioperative Registered Nurses.
To develop the guidelines, the Harvard team did two studies with W.H.O.
Using surgical data from more than one-fourth of the organizationâ€™s 192 member states, Dr. Gawandeâ€™s team estimated that 234 million major surgical procedures were undertaken each year worldwide. Of the total, 172 million, or 74 percent, were in the wealthier countries, and 40 million of those were in the United States.
The number of surgical procedures performed in a year is nearly double the number of births â€œand is probably an order of magnitude more dangerous,â€? Dr. Gawandeâ€™s team reported in an article in the journal Lancet, which was released on Tuesday.
The team also conducted a pilot study involving 3,600 patients in eight hospitals in poor and rich countries to determine whether using a checklist could help reduce surgical complication rates.
Data from the first 1,000 patients, which is expected to be reported at a meeting in Washington on Wednesday, showed that the use of a checklist increased adherence to standards of care to 68 percent from 36 percent, and approached 100 percent in some hospitals. Final results are expected later this year.
Some sites in richer countries did worse than ones in poorer countries, Dr. Gawande said. The researchers and hospitals agreed not to disclose specific data from individual institutions.
The hospitals included the University of Washington in Seattle; the University of Toronto; St. Maryâ€™s Hospital in London; the University of Auckland in New Zealand; Philippine General Hospital in Manila; Prince Hamza Hospital in Amman, Jordan; St. Stephenâ€™s Hospital in New Delhi; and the District Hospital in Ifakara, Tanzania.
Creating an accurate, functional checklist for surgery took many revisions, Dr. Gawande said, adding: â€œYou can make bad checklists and you can make good checklists. It is very easy to make a bad checklist that people want to throw away and never use.â€?