One of the most important determinants of a successful operation is ongoing effective communication between all members of the surgical team. The goal is for each member of the team to have a common understanding about the patient, the proposed operation, and the expected flow of the case—the “shared mental model.” One of the most common communication tools used in this setting is the surgical pause or “time-out.” While many institutions use a time-out, many of these are unstructured and therefore miss an opportunity to ingrain a culture of communication. In order to combat this, we strongly recommend using a structured and formalized checklist as part of the surgical pause. The prototype for this type of structured process is the World Health Organization Surgical Safety Checklist. The Surgical Safety Checklist, introduced in 2008, is a 19-point checklist to be used at 3 time points—immediately when the patient enters the operating room (prior to induction of anesthesia), just before the skin incision and just before the patient leaves the operating room. The checklist was tested in eight cities throughout the world to test its impact on patient morbidity and mortality. In a before-after study design, the investigators found that implementation of the checklist was associated with a significant reduction in mortality rate (1.5% vs. 0.8%, p < 0.01) and inpatient complications (11.0% vs. 7.0%, p < 0.01). While the checklist has largely been heralded as a success, some critics have asserted that it is not the checklist itself that reduces complications but rather the fact that the checklist provides an opportunity for the team to come together and discuss critical elements that are not to be missed. It is our opinion that it does not matter how the checklist works, only that it does.
Several additional studies have shown other benefits to introduction of a formalized checklist, including reduced mortality, morbidity, and hospital length of stay as demonstrated in a recent randomized controlled study that showed reduction in complications from 19.9% to 11.5% with introduction of the checklist. Despite this, some other studies of surgical checklists have shown no improvement in outcomes. This seems to be due to implementation issues, with wide variations in implementation between institutions and even between different specialties within an institution, with suboptimal implementation being common. Institutions who adopt a checklist in name only, but whose team members ignore or minimize the process, are unlikely to reap the benefits. On the other hand, institutions that develop a strong culture of safety with robust and mandatory implementation will see better results. This speaks to the importance of the etiquette of the OR—the code of conduct that regulates our actions. In order to derive the most benefit from the surgical safety checklist, all team members must be present and actively engaged in the process. Music should be turned off, side conversations stopped, and all attention should be focused on the checklist items and how they relate to the patient. Typically it is the role of the surgical attending, fellow, or resident to lead the checklist. As the designated leader, it is important to review and discuss each individual item on the checklist. This includes ensuring that every team member has introduced themselves and making it clear that all individuals in the OR are empowered to speak up if they become aware of a potentially unsafe situation. The checklist can be modified by individual hospitals or services to include relevant items specific to their patient population. For example, if a specific surgical team has additional items that must not be forgotten (e.g., processes regarding cardiopulmonary bypass in cardiac surgery), this can be included. Many checklists also include a debriefing section for use at the end of the case including items such as specimen processing, communication with the patient’s family, and who will accompany the patient to the postanesthesia or intensive care unit.