Synopsis of key findings
The WHO checklist improved recognised aspects associated with safe surgery in otolaryngology by improving verification of patient identity, and awareness of the patient’s medical condition and the side of the operation. In addition, the checklist enhanced communication between the surgical team members.
Strengths and weaknesses of the study
To our knowledge, this is the first study of its kind in otolaryngology. Our samples were relatively large and covered all subgroups of ORL-HNS surgery.
Some differences in the characteristics of the operations and patients were shown between the two study periods of 1 month each. The study groups consisted of consecutive operations and can be considered as selective convenience samples, a fact which weakens the study’s external validity.
Implementation of the checklist and concomitant answering to the questionnaire was challenging and required changes in routines. The response rate was high, and overall, the operating room personnel were supportive. Completing the questionnaire at the end of the operation can be considered a limitation. Answers might have been more precise immediately after the checks.
Comparisons with other studies
Our findings challenge the opinion of Karamchandani and McGarry10 in Clinical Otolaryngology that: ‘In ENT, we are unlikely to see immediate large benefits from the checklist because of the predominance of low mortality and low morbidity procedures. Perhaps only head and neck surgery exhibits the levels of risks that would demonstrate effect of significant size’. In fact, many adverse events are common with all kinds of surgeries, such as complications related to the WSPE. It is also known that communication breakdown is the most common cause of surgically adverse event.1–4,11
All age groups are represented in otolaryngology. The diseases are not usually associated with co-morbidities, and the operations do not cause immobilisation. The high number of outpatient surgeries, many carried out under local infiltration or regional anaesthesia, is also typical. The operations and patients in our series represented well these characteristics. One-fifth of the patients were children, and the majority of patients were in good medical condition.
Use of the checklist improved verification of patient identity, but this was still inadequate. It is absolutely essential to confirm the identity of the patient, even repeatedly. Awareness of the patient’s medical condition, medication, and even weight and height increased after checklist use. The check on weight and height was later added to the Finnish version of the checklist. In Paediatric Surgical Safety Checklist is a check on patient weight.8 Similarly, weight is relevant in otolaryngology because a substantial proportion of our patients are children.
Despite the development of preventative methods, wrong-side surgery (WSS) still occurs. A detailed review of wrong-side craniotomies describes a broad range of factors contributing to WSS, human error being the most prevalent factor. Most of these WSS could have been prevented. Bypassing preventive systems like preoperative checks and time-outs elevated the likelihood of WSS.3 Frequency of WSS is varying by surgical specialty and type of surgery.5 Wrong-side surgery has occurred in 6.1% of reported errors in otolaryngology.1 In a mail survey of otolaryngologists in North America, 9.3% of respondents knew of a case of wrong-side endoscopic sinus surgery.2
Our study revealed that awareness of side was insufficient. Some improvement occurred with the checklist, but this was not statistically significant (Table 3). However, the wrong side was written in two operation plans and was noticed when the checklist was used.
It is noteworthy that a time-out check was used in 32.4% of the wrong-site sinus surgery cases2 showing that these checks should be carried out with the utmost care. Dismissive replies, affirmative and inaccurate, are typical of a badly used checklist and poor use of a checklist will lessen its efficiency in preventing adverse events.12 In any case, the protocol of checking the side of the operation must be improved,3 and a properly used checklist is a good tool for this very important safety problem.
Communication failure is one of the leading factors contributing to surgical errors and medical adverse events, including WSPE.3,4,13 Use of standardised communication improves the information transfer process, with an effect on clinical and patient outcomes.14
Preoperative briefing has reduced communication failures.15,16 In our study, critical events were discussed more commonly between anaesthesiologists and otolaryngologists. The experience of successful communication between team members improved after checklist implementation. This has also been true in paediatric, trauma and orthopaedic series.8,17 The checklist also improved the recording of postoperative prescriptions and instructions and did not delay or prolong any operations in our series. In one study, preoperative briefing actually reduced operating room delays.15
Clinical applicability of the study
Our study confirms that the surgical checklist fits well into otolaryngology. After its introduction in 2009, several hospitals have made the checklist mandatory in Finland. We recommend the use of this checklist in all operations.