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PEARLS & PITFALLS – SURGICAL TECHNIQUE

Why I Use a Checklist in the Interestingly, the most stubborn opponent to the use of

Operating Room
a checklist in the operating room is often the surgeon.
The anesthesiologist, nursing staff, and surgical technicians

generally have no problem complying with the implementation
of a checklist. I believe surgeons have several motivations

for resisting the checklist, none of which are reasonable. By
implementing a checklist and involving multiple individuals, the
operating room staff is intentionally converted from a “surgeon
Robert Marx, MD
and his helpers” into a “team”. This teamwork concept has
Hospital for Special Surgery, been demonstrated to improve patient safety and decrease
New York, NY, USA
the risk of surgical error. Engaging everyone in the operating
room and making them part of the team caring for the patient

means team members are more likely to report potential
problems. For example, a unit assistant who cleans the

operating room and delivers the equipment will feel a greater
After I read Atul Gawande’s book, The Checklist Manifesto, sense of responsibility and have a greater sense of pride
a few years ago, I was convinced of the utility of a checklist
in their work, making them more likely to have the correct
in the operating room to improve safety. Gawande’s data equipment in the room. This prevents delays during the case
from his multi-center, multi-national prospective comparative and a more prolonged operating time. Also, the unit assistant

study published in the New England Journal of Medicine is may identify something as minor as having the arm board
persuasive, but the concept of a checklist is also intuitively on the wrong side of the operating room table for an upper

appealing. I have used checklists for many things in my extremity case. It is often small mistakes such as this that lead
personal life outside the operating room, so it was logical that to a cascade of errors that can culminate in a disaster, such

a checklist would help me get things right where it matters as wrong side or wrong procedure surgery.
the most.
Some surgeons, however, may feel that they are now
There are many advantages to using a checklist, including merely a member of the team and not “in charge.” In my

ensuring that we are operating on the correct patient and the experience, nothing could be further from the truth. Engaging
correct limb. However, one of my favorite parts of the checklist and empowering all team members improves both the
is the introduction of each individual by name and role at the atmosphere of the operating room and patient care. I have

beginning of each operation. The introductions are something also overheard surgeons saying that a checklist wastes time.
that put all members of the operating room team on equal In my experience, the checklist has actually saved time. For

footing as members of the team taking care of the patient. It is example, during the preoperative checklist, we routinely
critical that everyone introduce themselves before every case discuss what instruments and implants will be needed for

by name and role. If this is abandoned due to familiarity, it can the operation. Often, I will mention fixation devices or surgical
be awkward and intimidating for those who are not familiar to instruments that will be required but were not in the room

the team to speak up and introduce themselves. By making and not readily available. This discussion allows the operating
the introductions a routine, those who are new or unfamiliar room staff the opportunity to get the equipment before I need

to the team are not singled out. It also allows me to learn the it. Even at our hospital where we do only orthopedic surgery,
first and last names of all the people I work with. Since the we may have to wait five or ten minutes to get a piece of
implementation of the checklist, I have learned the names equipment when it was not anticipated. The checklist takes

of everyone in the operating room, and I now greet them by less than one minute to complete prior to surgery.
name every day. I believe this makes them feel more valued
Best of all, unlike many surgical innovations, there is no cost
in their job and more eager to facilitate the surgery and take to the surgical checklist. All it requires is commitment and
better care of the patients. They also feel more comfortable
leadership from the surgeon.
to speak up if they see something in the room that isn’t right.
This improved communication in the operating room has been

shown to result in better outcomes for patients.

38 ISAKOS NEWSLETTER 2013: Volume II