Correspondence

Checklists for Invasive Procedures

N Engl J Med 2013; 368:293-294January 17, 2013DOI: 10.1056/NEJMc1213329

Article

To the Editor:

In recent years, the World Health Organization (WHO) has undertaken a number of global and regional initiatives to improve the safety of surgical care. Its 2008 Safe Surgery Saves Lives campaign introduced the concept of a checklist, which was intended to identify and control risk during each of the three phases of an operation: before induction of anesthesia (“sign-in”), before incision of the skin (“time-out”), and before the patient leaves the operating room (“sign-out”). It has been well received by the spectrum of health care professionals in the operating room1 and has been shown to reduce mortality and morbidity.2

However, the concept has faltered in moving beyond the operating room, despite the rapidly expanding list of invasive procedures now taking place in nonsurgical, interventional specialties. The same sign-in, time-out, and sign-out phases are eminently applicable to procedures performed in the endoscopy suite, the cardiac catheter laboratory, and interventional radiology rooms. These patients are deserving of the same safety considerations that are being afforded to those undergoing an operation; the essential objectives listed by the WHO include appropriate consent, appropriate personnel and equipment, correct procedural site, avoidance of known allergies, contingency planning for complications, and optimization of thromboprophylaxis. It can be argued that certain WHO checklist points, such as displaying all essential imaging, are even more pertinent to, for example, endovascular procedures and coronary angiography, in which the pathologic features may not be externally evident.

One in 10 patients has an adverse event while in the hospital, and more than 40% of these events are considered preventable.3 Although the largest proportion of in-hospital adverse events are operation-related (39.6%), a sizable proportion (7.8%) relate to procedures in medical specialties.3 Recently, an interventional radiology–specific checklist was shown to reduce deviations from predetermined benchmarks by 19 percentage points and procedure postponements and cancellations by 10 percentage points.4 Checklists have also been devised in an attempt to lower the high rates of perforation and thromboembolism during cerebral aneurysm embolization.5 Further research is undoubtedly needed to empirically demonstrate the positive effect of checklists on patient safety outside the surgical sphere. This will facilitate the development of national standards and incentives for monitoring and improving outcomes.

Given the low-cost nature of checklists and the accumulating evidence in favor of their use with nonsurgical procedures, we believe that they represent an important and underused opportunity for cost-effective error reduction and quality improvement in medical specialties.

Thomas Marjot, M.B., B.S.
Imperial College London, London, United Kingdom
tm906@ic.ac.uk

Mahiben Maruthappu, F.R.S.A.
Harvard University, Cambridge, MA

Joseph Shalhoub, M.R.C.S.
Imperial College London, London, United Kingdom

Disclosure forms provided by the authors are available with the full text of this letter at NEJM.org.

5 References

1. 1

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   Haynes AB, Weiser TG, Berry WR, et al. A surgical safety checklist to reduce morbidity and mortality in a global population. N Engl J Med 2009;360:491-499
   Free Full Text | Web of Science | Medline

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   de Vries EN, Ramrattan MA, Smorenburg SM, Gouma DJ, Boermeester MA. The incidence and nature of in-hospital adverse events: a systematic review. Qual Saf Health Care 2008;17:216-223
   CrossRef | Web of Science | Medline

4. 4

   Koetser IC, de Vries EN, van Delden OM, Smorenburg SM, Boermeester MA, van Lienden KP. A checklist to improve patient safety in interventional radiology. Cardiovasc Intervent Radiol 2012 May 5 (Epub ahead of print).
   

5. 5

   Chen M. A checklist for cerebral aneurysm embolization complications. J Neurointerv Surg 2011 November 2 (Epub ahead of print).