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  • BIOETHICS FORUM ESSAY

A Patient’s Surgical Safety Checklist

I am a fourth year medical student who is about to start a surgical residency and who recently finished six weeks at The Hastings Center working as a visiting scholar on surgical error, patient safety, and quality improvement. At my final presentation, where I talked extensively about preoperative surgical checklists, I was asked if there was a checklist for patients about to get an operation.

Atul Gawande, attending surgeon at Brigham and Women’s Hospital in Boston, was recently asked the same question while on a book tour for The Checklist Manifesto, his new book about the proven benefit of checklists to reduce errors and improve patient safety. Dr. Gawande responded that, unfortunately, there is no formal patient checklist, but that having one would be helpful.

Despite this being an era burgeoning with information, I suspect that patients feel at the mercy of their doctors because they lack the information to make properly informed medical decisions and do not know what hazards they need to avoid. It does not have to be this way.

In January 2008 the American College of Surgeons conducted a nationwide survey that found that surgical patients spend an average of just one hour researching their surgery and surgeons. Shockingly, 36 percent of Americans who had an operation in the last five years never reviewed their surgeon’s credentials. Patients spend more time researching new cars before buying or leasing (eight hours) than their operations and surgeons.

There are a number of helpful resources for patients facing surgery, such as I Need an Operation…Now What? A Patient’s Guide to a Safe and Successful Outcome, by Dr. Thomas Russell, executive director of the American College of Surgeons. From resources like this, as well as my experience as a medical student going into surgery, I have created a basic patient’s surgical safety checklist.

When choosing the surgeon and hospital:

  • Check if the surgeon is board certified by the American Board of Surgery. Board certification indicates that a surgeon successfully completed an accredited surgical residency and passed rigorous written and oral examinations.
  • Check whether the surgeon is a member of professional organizations, such as the American College of Surgeons.
  • Check with state medical boards regarding a surgeon’s licensure, training, and history of disciplinary action.
  • Check how long the surgeon has been in practice (since completing fellowship, or since completing residency if the surgeon did not do fellowship). Some evidence suggests that surgeons who have been practicing for about five to ten years provide the best care, because they have had several years of operative experience as the primary surgeon, but also trained recently enough to be using the latest techniques.
  • Ask the surgeon about his or her experience with the operation you need (e.g., the number of times annually he or she performs the specific operation needed). The surgeon should do the operation at least 25 times a year – the more times, the lower the risk of complications, in general. Realize that in rural areas it will be harder to find surgeons with high volumes of the desired procedure, and weigh this risk against the inconvenience of traveling.
  • Check if the surgeon has admitting privileges at the desired hospital, and then check if the hospital is accredited by the Joint Commission, or check if the surgery center is accredited by the Accreditation Association for Ambulatory Health Care. Some hospitals and surgery centers are not accredited.
  • Assess the surgeon’s bedside manner, and decide whether you can establish a good and trusting doctor-patient relationship.
  • Ask the surgeon if he or she would be willing to use the World Health Organization (WHO) Surgical Safety Checklist, or if there is already a surgical safety checklist used at the hospital or surgical center.

 

Before the surgery:

  • Inform close family members and friends and arrange for someone to be there the day of surgery and to be available to help during the post-operative recovery period. Clearly designate one individual as the surrogate decision maker, and preferably establish one person as the durable power of attorney for health care. Discuss with this individual your preferences for life-sustaining treatment and other interventions given different post-operative personal capacities.
  • Ask your surgeon whether you should stop taking any medication before the surgery. Specifically, ask if and when you should stop taking aspirin, ibuprofen (e.g., Advil, Motrin), warfarin (Coumdin), or clopidogrel (Plavix), or any drug that might increase your risk of bleeding. Do not eat or drink anything for eight hours prior to surgery, and ask your surgeon if you will need a bowel prep, which consists of laxatives and possibly enemas.

On the day of surgery:

  • Bring all your pill bottles and several copies of the WHO Surgical Safety Checklist.
  • Tell the anesthesiologist if you have any bleeding disorders, allergies or adverse drug reactions, heart or lung conditions, a history of obstructive sleep apnea, diabetes, and/or use beta blockers – all of which can affect your risk for surgical or anesthetic complications. Mention if you have had problems with anesthesia. Inform the anesthesiologist of all medications you take and when you last took each one.
  • Make sure that the patient identification bracelet is accurate and contains your full name and date of birth.
  • Make sure that the surgeon marks the operative site in the preoperative holding area if it is a sided-surgery (e.g., a right versus left knee replacement).

In the operating room:

  • Make sure that the anesthesiologist gives a prophylactic antibiotic.
  • Make sure that serial compression devices are placed (boots that squeeze the calves to prevent blood clots from developing).
  • Before being put under anesthesia remind the operating room staff of your name, the surgical procedure, and surgical site.

In the postoperative recovery period:

  • Use the incentive spirometer frequently (several times an hour) to help reinflate your lungs and prevent atelectasis (partial lung collapse), which can lead to pneumonia.
  • Walk as much as possible as soon as possible (to prevent blood clots from developing), but with supervision at first while the anesthesia is still wearing off.
  • Leave on the sterile dressing over the surgical incision for at least two or three days, and do not submerge it in water (e.g., a bathtub or swimming pool) for several days to reduce the risk of infection.
  • If a Foley catheter was placed into your bladder, ask the surgical team to remove it as soon as possible to prevent a urinary tract infection.
  • Take as many pain medications as you need to feel comfortable, but realize that narcotics delay the return of bowel function and lead to constipation; you can ameliorate this by walking and taking stool softeners (ask the surgical team for them).

Patient surgical safety checklists deserve more research. They have the potential to make surgery safer, and to help empower patients during a difficult and scary time.

Scott B. Grant, a fourth year medical student at Brown University, will begin general surgery residency this summer at Robert Wood Johnson University Hospital.

Published on: March 23, 2010
Published in: Health and Health Care

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