In many of our lectures and written updates to the veterinary community, we discuss tools and procedures that allow us to achieve improved patient outcomes. This may be a new diagnostic test, a million-dollar imaging unit, a (literally) shiny new surgical implant or a recently-approved medication. Some of what we share does not cost money to acquire, but is instead a novel conceptual approach, for making a particular diagnosis or carrying out treatment; yet there may still be a learning curve. What I offer to you today is free of charge and, once created, is designed to be free of mental effort. I offer you … a checklist.
As many of you may have heard and read (I have not, it is on my to-do list), The Checklist Manifesto, penned by the Harvard surgeon Atul Gawande, espouses the benefits of incorporating checklists into many facets of life. It is in medicine, where the complexity of decision/action are so great, and the stakes of a misstep so maximized, that this tool and a sort of philosophy that goes along with it may be most at home. Some of the most intuitive implementations are for “packages” of information or action that get repeated regularly and do not necessarily require great creative or intellectual power to carry out, but that consist of enough complexity and/or potential variability that our own memory may not be the most reliable repository of said data.
At this point, the data is coming in on the matter, and the veterinary literature includes a prospective study on the use of checklists on 520 dogs and cats. The authors looked at the number and severity of complication rates in consecutive patients operated (orthopedic and soft tissue surgery) and hospitalized before (300) and after (220) implementation of a series of checklists which were patterned after those created by the World Health Organization. In this population of patients, complication rates went from 17% to 7%, including infections and other wound healing complications. Complications of almost every nature and severity, including death, were reduced, although numbers of patients in each group were not always enough to be significant.
Techniques and practices would generally be expected to improve over time and this may have slightly confounded the results, as the checklist group followed the non-checklist group. Also noted by the authors, institution of the checklist may very well have introduced a behavioral bias, causing staff to be more cognizant of matters at hand in order to comply. To this I say, and I hope you say with me, “so what!”… that’s what it is for.
Of course, the concern and the hurdle are implementation. Seems like another thing to do that will slow things down. I can only share my experience. We have been using a surgical/anesthetic checklist for close to 2 years now. The process takes anywhere from 30 seconds to 2 minutes. It doesn’t add time to our workflow; it replaces a good amount of inefficient communication (which is statistically responsible for the vast majority of medical errors). Does it catch mistakes and omissions? All the time. Little things (client requested a toenail trim, doesn’t want a call until surgery is over, give him a kiss on the head at induction and tell him that “Mamma loves him”) and not-so-little things (what are the anticipated anesthetic risks, we are also taking that mass off, we need pre-op radiographs of both stifles, we need to confirm that we have the 14-hole plate and bone graft, confirmed review of bloodwork, etc.). Now that we are in tune with what we are going to go over and the whole team is on the same page, many of the questions that would come up are anticipated and addressed before the formal run-through occurs; and it is a mindset. We standardized our behavior and organize our workflow around maximizing patient care and making sure those things that need to be done, have been done. I think we would all feel a little lost, a little strange and a little careless without it at this point. Right now all anesthetic procedures, for all departments, done at both VSH locations require the completion of a checklist.
I hope this inspires some to try it out. It can start small and it most likely would evolve, and should. And if you’re out and see it, you can get me a copy of that book. And some toilet paper. I forgot to pick some up today. My wife forgot to send me with a checklist.
- Atul Gawande, The Checklist Manifesto. 2009, Metropolitan books. Amazon
- Jauhar S. One Thing After Another. NY Times, 2010-01-22
- Bergström A, Domopoulou M, Eldh M. Reduction of surgical complications in dogs and cats by the use of a surgical safety checklist. Vet Surg 2016;45:571-6. Abstract
About the author
Dr. Seth Ganz obtained his doctorate of veterinary medicine from Tufts University School of Veterinary Medicine, North Grafton, Massachusetts, in 2005.In 2005-2006, he completed an internship in general medicine and surgery here at the Veterinary Specialty Hospital. He stayed with VSH for an additional year, completing a surgery internship. Dr. Ganz then went on to complete a 3-year small animal surgical residency at Fox Valley Animal Referral Center in Appleton, WI and became board-certified by the American College of Veterinary Surgeons in 2011.
Dr. Ganz has special interests in all aspects of orthopedic surgery including treatment of cranial cruciate ligament disease and joint replacement. Interests in soft tissue surgery include oncologic, abdominal, and reconstructive surgery. He also has training in neurosurgery. Dr. Ganz’s research interests have included lower respiratory tract trauma, urinary tract disease, and complications of total hip arthroplasty. Dr. Ganz is passionate about small animal surgery and is rewarded by the opportunity to benefit the lives of his patients and their human companions.