The lifesaving power of checklists: what you need to know now

This is article fourteen in an RCVS Knowledge series of features on patient safety, clinical human factors, and the principles and associated themes of Quality Improvement (QI).

At the end of another manic day at Park Lane Vets, Craig is stocking up. As he wanders to the storeroom, he recites the list of things he needs. “Size 7 surgical gloves, drapes, propofol, swabs, T-ports, bandaging stuff, bungs, 2ml syringes, clinical waste bags and some throat packs… 10 things”. Lisa passes him in the corridor: “need a hand, Craig?”

“Thanks Lisa, if you could help me carry a few bits that would be great – save me making multiple trips,” Craig replies happily. “Now what was it we needed… Size 7 surgical gloves, drapes, propofol, swabs, T-ports, bandaging stuff, clinical waste bags and... Hmmm.” Craig pauses. “Why can’t I remember the rest of my list?”

I think the moment the importance of checklists was cemented in my mind was shortly after being asked, “how many things can you keep on your mental scratch pad at one time?”

In the field of cognitive psychology, chunking¹ has been shown to increase our working memory, however for most of us the answer is seven (plus or minus two), and that’s only if you don’t get distracted by another task in the meantime². Only seven?! Well, that certainly explains why Craig can’t remember all 10 things on his list. It also suggests why things are forgotten in the hospital environment. We simply can’t remember everything. So, checklists can help us ensure we keep our patients safe.

If you need any further persuasion, the statistics are pretty impressive! Studies on the success of the World Health Organisation Surgical Safety Checklist reported:

• 47% reduction in deaths
• 36% reduction in post-operative complications
• 48% reduction in infections

Checklists have also been found to improve communication and team cohesion in the operating theatre, and they are a simple and low-cost intervention³.

Research has found that the frequency and severity of post-operative complications significantly decrease after introducing Surgical Safety Checklists in the veterinary profession. Their implementation leads to decreased anaesthesia duration, increased administration of planned perioperative antibiotics before incision, increased completion of safety measures and decreased unexpected return to the operating theatre^4,5.

Which checklist?

But which checklists do you go for? Personally, there are two clinical checklists that I couldn’t do without: the anaesthesia checklist and the surgical safety checklist. My advice is to start with these two and create more to suit your clinical setting. It is vital that time is dedicated to implementing and embedding each checklist into daily practice for every patient, to avoid them being relegated to a dusty folder in the corner of the prep room. It is also vital that the checklist is modified to suit your clinical setting and regularly reflected upon and updated to ensure greater participation and ownership. Each stage of the checklist should take less than 60 seconds to ensure that it remains efficient and to avoid checklist fatigue.

It should also be remembered that the benefits of checklists extend beyond our clinical needs, wellbeing checklists such as the going home checklist can also enhance patient safety through maintaining staff wellbeing.

Tips for checklist implementation

A multifaceted approach should be used when introducing and implementing checklists in practice.

1.      Ensure that the right support, such as equipment and processes, is in place before implementation begins.

2.      Ensure that the checklists can be accessed easily, and that everyone knows how to access them. For example, they could be pre-printed, designed to be print-ready, available at a central location on the computer system or laminated so that they are reusable and easy to clean.

3.      Spread the word; start with colleagues who are likely to be supportive and build a team of strong leaders who are prepared to champion the checklist.

4.      Take time to present and explain the checklist to the whole team, emphasising the benefits, for example lower complication rates, increased patient safety, decreased costs.

5.      Implement the checklist in one area, to begin with, encourage feedback, work through any concerns individuals have and customise the checklist to suit the setting in which it is to be used. Once enthusiasm builds, any wrinkles have been ironed out, and the benefit of using the checklist has been demonstrated, extend to other areas.

6.       Audit the checklist regularly to ensure that it remains current, and changes are made as necessary to reflect updates in evidence-based veterinary medicine.

Designating and empowering a checklist co-ordinator

The World Health Organisation (WHO) recommends that a single person should be made responsible for managing the Surgical Safety Checklist. In practice, this will often be a circulating nurse, however any member of the team may complete the checklist. The responsible person should feel empowered to ensure that all team members listen and participate attentively in the checklist to communicate effectively.

Non-urgent interruptions should be discouraged and the person leading the Surgical Safety Checklist should feel comfortable stopping the flow of the checklist to politely remind all team members present that their full attention is required. The checklist should be halted if there is difficulty confirming a point (e.g., identifying the patient, confirming owner consent) and resume when confirmation is made.

These lessons can be adapted and applied in the use of any checklist.

Checklists: just a tick-box exercise?

In aviation, where checklists originated, checklists detail tasks to be performed at specific times. For example, before take-off the pilot should confirm that the tail wheel is locked, the gyro is set, and generators are on. The anaesthetic machine checklist is similar; is the vaporiser full? Is the oxygen flush working? Has the anaesthesia circuit been leak tested⁶?

The Surgical Safety Checklist has a little more to offer though; there are some yes or no questions such as: has the surgical site been identified and agreed as a team? However, it can also be used to inspire teams to consider the patient and plan their journey through induction and surgery to recovery by ensuring optimal communication and shallowing hierarchy.

During the sign-in phase, when asked if there is a risk of greater than 15% blood loss, the team should discuss the plan should blood loss occur. Is there adequate IV access, or should another intravenous catheter be placed? Has the patient been blood-typed? Is there blood in stock? Has it been labelled for this patient? Who will fetch it if it’s needed? The checklist should also be colour-coded to indicate which areas contain information that should be handed over if the circulating nurse changes at the end of a shift or lunch break (see the examples in RCVS Knowledge’s Surgical Safety Checklist Manual, link below).

As you can see, a checklist is not just a tick-box exercise. Each yes or no prompt represents an integral activity that needs to be completed by the team.

Like Craig, we are all human. We can only remember a certain number of things at a time. When practices are overwhelmed with patients and struggling to recruit new staff, clinical checklists offer a safety net. They free up capacity to focus on crucial tasks and reduce anxiety, so that when you get home you can put your feet up without worrying that you might have forgotten something.

Checklist – what you can do next

• Visit the Quality Improvement page at RCVS Knowledge for free resources, including the Surgical Safety Checklist Manual, access checklist templates and case examples and CPD for all you want to know about surgical safety checklists.
• Listen to Pam Mosedale, BVetMed MRCVS and Chair of the Quality Advisory Board, explain how and why to use checklists in veterinary practice.
• Listen to the Knowledge Sessions podcast 'The life-saving value of checklists', where Amanda Boag, current Chair of RCVS Knowledge's Board of Trustees, discusses the proven power of checklists to reduce avoidable errors and significant events.
• Checklists should be based on the best available evidence. RCVS Knowledge has a free course introducing the concepts of Evidence-based Veterinary Medicine, which you can take at your own pace.
• Have a look at this excellent article on patient safety by Louise Northway RVN, discussing how planning, preparation and teamwork, including the use of checklists are so important, with resources and tips aplenty!
• Check out the Anaesthetic Safety Checklist published by the Association of Veterinary Anaesthetists for a handy template.
• Remember, checklists are also there to support the team. Check out the RCVS Knowledge rolling-take-5 checklist adapted from the NHS England 'Going home checklist' to see the steps we can all take at the end of a busy day to safeguard our wellbeing.

References

1. Thalmann, M., Souza, A. S. and Oberauer, K. (2019) How does chunking help working memory? Journal of Experimental Psychology: Learning, Memory, and Cognition, 45 (1), pp. 37–55. https://doi.org/10.1037/xlm0000578 
2. Miller, G. (1956) The magical number seven, plus or minus two: some limits on our capacity for processing information. Psychological Review, 63 (2), pp. 81-97. https://doi.org/10.1037/h0043158
3. Surgical Safety Checklist Manual [RCVS Knowledge] [online]. Available from: http://www.rcvsknowledge.org/document-library/surgical-safety-checklist-manual/ [Accessed 2 November 2021]
4. Thieman Mankin, K.M., Jeffery, N.D. and Kerwin, S.C. (2021) The impact of a surgical checklist on surgical outcomes in an academic institution. Veterinary Surgery, 50 (4), pp. 848-857. https://doi.org/10.1111/vsu.13629
5. Bergström, A., Dimopoulou, M. and Eldh, M. (2016) Reduction of surgical complications in dogs and cats by the use of a surgical safety checklist. Veterinary Surgery, 45 (5), pp. 571-576. https://doi.org/10.1111/vsu.12482
6. Anaesthetic Safety Checklist [Association of Veterinary Anaesthetists] [online]. Available from: https://ava.eu.com/wp-content/uploads/2015/11/AVA-Anaesthetic-Safety-Checklist-FINAL-UK-WEB-copy-2.pdf [Accessed 2 November 2021]

About the author

Helen Silver-MacMahon MSc (Dist) PSCHF Cert VNECC DipAVN(surg) Cert SAN RVN

Helen is a veterinary nurse and Senior Trainer and Content Development Lead at VetLed. Having worked in general practice, referral hospitals and nursing education over the past 21 years, she has extensive professional experience and understanding from a wide range of  settings.

Helen is passionate about developing the veterinary professions understanding of Human Factors as a powerful aid in improving patient safety, enhancing performance and supporting the wellbeing of the veterinary team. She is an RCVS Knowledge Champion for her role in the sustained training and use of a surgical safety checklist within the small animal theatre at the former Animal Health Trust.

In 2021, Helen completed an MSc in Patient Safety and Clinical Human Factors at the University of Edinburgh.

For her dissertation project Helen researched situational awareness in the veterinary operating theatre and has a special interest in non-technical skills. In her role at VetLed she enjoys applying this knowledge to develop and deliver professionally relevant training for all members of the veterinary team.