A year-long World Health Organization pilot program in eight hospitals around the world--including the University of Washington Medical Center (UWMC) in Seattle--has proven conclusively that inpatient deaths can be significantly reduced, along with the rate of major complications after surgery, by following a simple checklist. UWMC is the only U.S. hospital to participate in the pilot phase of the WHO program. Results from the program appear in the Jan. 29 issue of the New England Journal of Medicine.

Dr. Patchen Dellinger, UW professor and vice chair of the Department of Surgery, said analysis of studies undertaken in the eight hospitals showed that the rate of major complications fell from 11 percent in the baseline period to 7 percent after introduction of the checklist. At the same time, inpatient deaths following an operation fell by more than 40 percent with the implementation of the checklist.

Health-care teams in the Division of General Surgery at UWMC began using the checklist in April 2008. Complications related to surgery were significantly decreased after checklist implementation, and a survey conducted after the pilot phase of the project found that an overwhelming majority of personnel in UWMC operating rooms would want a checklist used if they were having an operation.

The checklist--which is similar to lists used by pilots before take-off--takes only a few minutes to complete at three critical points during operative care: before anesthesia is administered, before skin incision and before the patient leaves the operating room.

What items are covered on the checklist? Before a patient is rolled into the operating room, medical center staff ask the patient to confirm his or her identity and the procedure. Once in the operating room, all team members introduce themselves by name and role.

Dellinger said the UW "jumped at the chance to be a pilot site" for the WHO initiative. "A lot of us feel as if we don't know why the checklist hadn't been there" all along, he said. Not all reactions were initially positive, he admitted. "One surgeon said, 'It sounds like a good idea as long as I don't have to do anything I'm not already doing,'" Dellinger said, with a chuckle.

The safe surgery checklist initiative was launched throughout the world in June 2008 following the pilot program, and has been led by Professor Atul Gawande, a renowned surgeon at Harvard School of Public Health.

"In Seattle, we have been extremely involved in making sure the checklist works locally and that our operating room staff understands the benefits," Dellinger said. "We hope that other hospitals in the state of Washington and the United States will implement use of the checklist and introduce it locally. The long-term benefits are considerable for patient safety." The WHO hopes 2,500 hospitals worldwide will be using the checklist by the end of the year.

In Washington state, the Surgical Care and Outcomes Assessment Program (SCOAP) has adapted and added to the WHO checklist to address process issues that arose during initial use of the checklist. Items added to create the WHO/SCOAP checklist include the use of blood thinners to prevent blood clots following operation, the use of insulin to control blood sugar in diabetics, and plans for a second dose of antibiotics for operations that continue for more than three hours.

SCOAP is a Washington state collaborative of surgeons that involves 42 hospitals and provides data regarding the use of the checklist and other measures, with an aim of reducing surgical complications. SCOAP has assembled a coalition of hospitals, professional organizations, health insurance companies, employers, and nonprofit organizations to promote the use of the checklist in every hospital and every operating room in the state of Washington by the end of 2009. Fifteen hospitals to date, including the University of Washington Medical Center and Harborview Medical Center--both UW Medicine entities--have adopted this checklist.