The Surgical Safety Checklist: Lessons Learned During Implementation JAMES FORREST CALLAND, M.D.,* FLORENCE E. TURRENTINE, R.N., PH.D.,* STEPHANIE GUERLAIN, PH.D.,† VIKTOR BOVBJERG, PH.D.,‡ GARRETT R. POOLE, M.D.,† KELSEY LEBEAU, B.S.,† JAMES PEUGH, PH.D.,§ REID B. ADAMS, M.D.* From the *Department of Surgery, University of Virginia School of Medicine, Charlottesville, Virginia; †University of Virginia School of Engineering and Applied Sciences, Charlottesville, Virginia; ‡University of Virginia Department of Public Health Sciences, Charlottesville, Virginia; and §University of Virginia Curry School of Education, Charlottesville, Virginia Procedural checklists may be useful for increasing the reliability of safety-critical processes be- cause of their potential capacity to improve teamwork, situation awareness, and error catching. To test the hypothesized utility and adaptability of checklists to surgical teams, we performed a randomized controlled trial of procedural checklists to determine their capacity to increase the frequency of safety-critical behaviors during 47 laparoscopic cholecystectomies. Ten attending surgeons at an academic tertiary care center were randomized into two equal groups - half of these surgeons received basic team training and used a preprocedural checklist whereas the other half performed standard laparoscopic cholecystectomies. All procedures were videotaped and scored by trained reviewers for the presence of safety-critical behaviors. There were no differences detected in patient outcomes, case times, or technical proficiency between groups. Cases per- formed by surgeons in the intervention (checklist) group were significantly more likely to involve positive safety-related team behaviors such as case presentations, explicit discussions of roles and responsibilities, contingency planning, equipment checks, and postcase debriefings. Overall, situational awareness did not significantly differ between the intervention and control groups. Participants in the intervention (checklist) group consistently rated their cases as involving less satisfactory subjective levels of comfort, team efficiency, and communication compared with those performed by surgeons in the control group. Surgical procedural safety checklists have the ca- pacity to increase the frequency of positive team behaviors in the operating room during lapa- roscopic surgery. Adapting to the use of a procedural checklist may be initially uncomfortable for participants. O PERATING ROOMS are complex and highly technical environments where surgical teams are expected to synthesize, retain, and communicate large amounts of information. The risks for error in the surgical en- vironment are considerable, with operative adverse events found to comprise 45 per cent to 66 per cent of all adverse events occurring within hospitals. 1, 2 In one study on medical errors, nearly 80 per cent of reported surgical adverse events occurred intraoperatively with almost a third resulting in permanent disability and 13 per cent in patient death. 3 Communication failures among personnel were cited as the second most com- mon systems factor contributing to errors, only behind inexperience or lack of competence by the surgeon. Although the methodology of such retrospective-based investigations have been questioned, they represent some of the most comprehensive studies of medical errors to date in the medical literature. 4 Furthermore, a recent prospective study of surgical patients revealed complication rates 2 to 4 times higher than those identified in an Institute of Medicine report. 5, 6 Mor- tality rates from avoidable complications ranged from 19.0 per cent to 44.1 per cent depending on the surgical service. Together, these studies reveal substantial op- portunity for improvement in operating room safety. For many years, experts in high-risk domains other than surgery have used checklists to reduce the fre- quency of human error in the completion of complex, multistep tasks. Commercial pilots, for instance, use safety checklists during critical portions of flights to This work was funded by a grant from The National Patient Safety Foundation, 268 Summer St., 6 th Floor, Boston, MA 02210, http://www.npsf.org/. Address correspondence and reprint requests to James Forrest Calland, M.D., Assistant Professor of Surgery, Department of Surgery, University of Virginia Health System, Box 800709, Private Clinics: 4553, Charlottesville, VA 22908. E-mail: calland@ virginia.edu. 1131