​A WHO checklist intended to make surgery safer was not living up to its potential. Singapore General Hospital confronted the failures and successfully brought the number of adverse events down to zero.

SGH adopted the checklist when it was launched in 2009 as a tool designed to encourage open communication among the team in the Operating Theatre as there was evidence that it reduces surgical complications.   

A series of recent adverse events prompted the hospital to undertake a review. Root-cause analysis of the adverse events, direct observations of what happens in the operation theatre and a surgical checklist survey found that staff were using the list in a perfunctory manner. They did not know the rationale for the list and were at times merely going through a box-ticking exercise.

SGH recognised that the list could still prevent incidents if it was improved and used properly. So the hospital decided to review and improve the list.

Associate Professor Tan Hiang Khoon, then Chairman of Division of Surgery & Surgical Oncology, appointed a multi-disciplinary team - led by Dr Yong Tze Tein - and in collaboration with Ariadne Labs to explain the purpose and to gather feedback from all surgical departments on how they want the checklist to be. 

Two years later after the re-launch in November 2021, they managed to reduce adverse events from two per quarter to zero. Indicators for patient safety culture also improved in nine out of 12 areas, including better team communication.

The art of making a checklist

There were requests for customised lists for each specialty, which the project team did not agree with.

"Our team believed in one standardised checklist for all. This simplifies matters and ensures consistency. This is especially important in emergencies when you may not have your usual team to work with," says Prof Yong.

"Making a checklist is an art – too short and it's not effective; too long and people will take short cuts. Staff asked if they could only do the relevant bits. But you should not skip parts of a checklist as you never know when a question might be relevant. At the end of the day, we are all human and can forget, or be distracted. The purpose of the checklist is to remind us of the small things that may be crucial for the patient," she elaborates.

Encourage speaking up

Root Cause Analysis of cases indicated that the culture of speaking up needed to be reinforced.

Phrase questions better

"My operation is shorter than your check list!" That was a common reaction to the list. Acting on such feedback, the team removed repetitive questions.

They also rephrased ambiguous ones, such as "Any significant blood loss?". Prof Yong explains, "But what is 'significant'? Now the question has been amended to 'What is the estimated blood loss?'"

Define roles clearly

Another improvement is to have every member introduce themselves and be responsible to lead one part of the list, with their roles clearly defined. This ensures every team member participates actively during the safety Time Out. It also empowers team mates to talk to one another and voice safety concerns.

Share learnings

To help staff understand the intent of the checklist and to get their buy-in, Prof Yong and her team held many roadshows for departments. "We shared stories on incidents that happened here, to make them see that this was happening at SGH, not another hospital. Our message was, 'It could happen to you and me. The patient could be someone close to you.' By sharing adverse events and near-misses, we hope that staff can learn from these cases so that the incidents would not be repeated."

To change behaviours, the team produced training videos to show best practices. To signal their support, surgical leaders were cast in these videos.

Safer for staff, too!

"Re-implementing the improved surgical safety checklist has also made work safer for all. Now, the whole team – rather than relying solely on the surgeon - chip in to look out for the patient. By making surgery safer, we make it less stressful for everyone. For every Serious Reportable Event that happens, there would be a Root Cause Analysis and sometimes Medico-Legal hearing or an inquiry. These drain the medical team emotionally and distract them from patient care," says Prof Yong.

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