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25 October 2011
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Could the checklist make surgery less safe?

By Duncan McPherson

I am known at my hospital for having worked at the National Patient Safety Agency. People approach me frequently with queries about the surgical safety checklist. Nearly all questions I can answer easily, but last week I was posed a problem that I still haven’t really got a good answer for.

We know, partly from work by Rhona Flin, that being subject to rudeness degrades one’s performance. Also, merely witnessing others being the subject of rudeness has the same effect. So, if someone were to be openly rude and aggressive in an operating theatre there is the potential to degrade the performance of the entire theatre team.

A consultant anaesthetist posed the question to me. Her role, as well as giving the anaesthetic, is to maximize the performance of the theatre team. The checklist is one of the weapons in her armoury. But what if she can predict that someone will sabotage the checklist process by, for example shouting at the person asking the checklist items or responding with facetious answers?

Obviously the answer is that the saboteur should be subject to the usual range of measures ending with disciplinary action. We should also look at the overall culture of the organization and teamwork etc. But these are all medium- or long-term measures that take time to put in place. What should she do in the short term, in the next five minutes? Graded assertiveness may be the answer, but once the atmosphere in a theatre is spoilt it stays spoilt for the rest of the list. Could it be possible that she should make a decision not to try and use the checklist because it is likely to make the patient less rather than more safe?

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Duncan McPherson's picture

Duncan McPherson

Duncan is a Specialist Registrar in Anaesthesia and Pain Medicine in Wessex. He is researching an MD on patient safety.

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Comments

12 years 2 months ago

Surgical Checklist

The surgical checklist is only one part of making surgery safer and the mainstay is to work as a team starting with a briefing session with the staff in the theatre as to what we are doing on the list any issues from the teamabout kit and the patients them selves. this helps before the task of completeing the checklist and is good for team building experience. might I suggest that everyone in the team needs to be challenge indivuals like this about inappropriate behaviour

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12 years 5 months ago

Could the checklist make surgery less safe?

I think the answer to the header question is an unequivocal "no"....while recognising that there will be isolated times when a checklist mentality appears to be involved in generating error.
In the specific case you mention, there are a number of options here but the key thing for me is that the question is being asked at all. That suggests not that this is something that might happen, but that it is something that has ALREADY happened. And if either is the case, then surely the next leadership move the anaesthetist has to make is to work out an intervention that will prevent a recurrence of the behaviour. There would be a range of things in the toolkit, from an individual discussion (try books like "Crucial Conversations" or "Crucial Confrontations" from the Kerry Patterson stable for scripts for that kind of conversation) in a suitable place, through enlisting colleague support, to a group intervention (just suppose the whole theatre team aside from the surgeon all calmly and assertively supported the checklist and supported calm challenge) or ultimately escalation through (medical) managerial pathways. Can this be dealt with "playfully" through the right kind of challenge from someone he knows well who he respects? Can the reason for the checklist be emphasised including with the unit's own data on serious events before and after implmentation. Ultimately there may have to be an "authority" conversation but there may be other possibilities first.
Checklists can of course lead to danger if they become mechanical. I think they need a level of continuous reinvigoration and reinvention because what really makes them work is legitimacy of content and ownership, for which the users must be intellectually on board. This is of course beautifully set out by Atul Gawande in the The Checklist Manifesto (just in case any readers have not drunk that particular Kool-Aid yet).

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