• Jaishankar Raman, Nancy Leveson, Aubrey Lynn Samost, Nikola Dobrilovic, Maggie Oldham, Sidney Dekker, and Stan Finkelstein.
• Division of Cardiothoracic Surgery, Oregon Health & Science University, Portland, Ore. Electronic address: jairaman24@gmail.com.
• J. Thorac. Cardiovasc. Surg. 2016 Aug 1; 152 (2): 585-92.

ObjectivesChecklists are being introduced to enhance patient safety, but the results have been mixed. The goal of this research is to understand why time-outs and checklists are sometimes not effective in preventing surgical adverse events and to identify additional measures needed to reduce these events.MethodsA total of 380 consecutive patients underwent complex cardiac surgery over a 24-month period between November 2011 and November 2013 at an academic medical center, out of a total of 529 cardiac cases. Elective isolated aortic valve replacements, mitral valve repairs, and coronary artery bypass graft surgical procedures (N = 149) were excluded. A time-out was conducted in a standard fashion in all patients in accordance with the World Health Organization surgical checklist protocol. Adverse events were classified as anything that resulted in an operative delay, nonavailability of equipment, failure of drug administration, or unexpected adverse clinical outcome. These events and their details were collected every week and analyzed using a systemic causal analysis technique using a technique called CAST (causal analysis based on systems theory). This analytic technique evaluated the sociotechnical system to identify the set of causal factors involved in the adverse events and the causal factors explored to identify reasons. Recommendations were made for the improvement of checklists and the use of system design changes that could prevent such events in the future.ResultsThirty events were identified. The causal analysis of these 30 adverse events was carried out and actionable events classified. There were important limitations in the use of standard checklists as a stand-alone patient safety measure in the operating room setting, because of multiple factors. Major categories included miscommunication between staff, medication errors, missing instrumentation, missing implants, and improper handling of equipment or instruments. An average of 3.9 recommendations were generated for each adverse event scenario.ConclusionsTime-outs and checklists can prevent some types of adverse events, but they need to be carefully designed. Additional interventions aimed at improving safety controls in the system design are needed to augment the use of checklists. Customization of checklists for specialized surgical procedures may reduce adverse events.Copyright © 2016 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.

37 keywords...

hide…