The need for a comprehensive checklist was realized in October 1935 when Boeing Corporation’s new 4-engine plane stalled soon after takeoff. An investigation revealed the cause was “pilot error”. A new locking mechanism for the elevator and rudder controls was not released. The new plane was complex and determined to be, “Too much airplane for one man to fly.” Today, checklists in the aviation industry are ubiquitous and the industry’s safety record is extraordinary.
Checklist use in the medical industry has not had the same success of widespread adoption. Yet, the complexity of surgical preparations and procedures can exceed that needed for a modern aircraft.
The Joint Commission for Hospital Accreditation and the Veterans Administration has published guidelines to perform a formal, preprocedural Time-Out with a checklist used for verification.
The Checklist Boards Corporation of Rochester, NY has a solution.
The company’s president, Rick Taylor explains:
“We listened carefully to our partner hospital’s surgery managers and patient safety officers. We designed a model checklist with the features most needed for surgical error prevention before, during and after procedures.
We evaluated several checklist formats. Here are the findings:”
A wall-mounted, interactive, acrylic Checklist Board is best.
Large format up to 48” wide
Easy to read from several feet away
Encourages full participation
Checklist item status easy to see as red (no) or green (go)
Operates flawlessly for years – easy to clean
Single person operation discourages participation
Availability and function-of-device issues
Multiple participation, durability and quality issues
The Joint Commission has as a 2015 National Patient Safety Goal, the Universal Protocol, UP.01.01.01, for Preventing Wrong Site, Wrong Procedure, and Wrong Person Surgery. It includes detailed information on the rational and elements-of-performance to implement a preprocedural Time-Out process and verification.
The Veterans Administration introduced Directive VHA 1039 to Ensure Correct Surgery and Invasive Procedures. As with the Joint Commission’s Universal Protocol, the V.A.s directive includes detailed information to ensure procedures are performed on the correct patient, at the correct site, and with the correct device/implant.
The need for these surgical patient safety guidelines is due to the continuing incidence of preventable surgical errors of omission, commission and misidentification. For example:
Wrong Procedure – 1000+ times per year
Wrong Site/Side – 1000+ times per year
Retained Items – 2000+ times per year
The Time-Out process and Checklist Board are the last line-of-defense to catch potential errors missed during the pre-operative phase.
Here is an example of a good Checklist Board Time-Out:
Senior management actively supports the implementation
All staff are empowered to, “Call a Safety Stop” when needed
The Time-Out begins when all staff are ready
The Time-Out Team Leader asks for “Everyone’s Attention”
Full-participation and silence are required
Each team member announces their name and role
Each line of the Checklist Board is verified as complete/correct
Team members are encouraged to Speak-Up for safety
Case specific announcements and Team Leader chart sign-off
“The Checklist Board Corporation has had the privilege to install thousands of boards in hundreds of hospitals across the country.
We welcome your questions about how to introduce a Checklist Board Time-Out Campaign at your hospital or clinic. We freely share success stories of past successful Checklist Board implementations, “added Mr. Taylor.