Surgery checklists save lives—Use them

Checklists have been shown, in medicine and countless other fields, to decrease mistakes, reduce complications, and save lives

Checklists have been shown, in medicine and countless other fields, to decrease mistakes, reduce complications, and save lives
The surgery board is a great place for checklists.
Photo courtesy Phil Zeltzman

Even on the busiest shift, you can minimize the risk of making a mistake or forgetting something important. How? By using checklists.

Think about it. Without a checklist, a plane would never take off, a skyscraper would never be built, a liver would never be transplanted. This indispensable tool has been popularized by the bestselling book, The Checklist Manifesto, by human surgeon Atul Gawande, MD, MPH. How can we adapt them to our practices?

OR prep

Before the crack of dawn, the surgery fairy sets everything up to ensure a smooth day for all. The OR pre-op checklist includes:

  • Leak test of all anesthesia machines
  • Pop-off valves open
  • Soda lime appropriate
  • Supplies refilled (scrub, alcohol, gauze, eye lube, dry syringe)
  • Turn monitoring equipment on
  • Warming equipment ready to start
  • Oxygen level checked
  • Anesthetic gas level checked
  • Suction and cautery prepared
  • Enough ties, clean and ready
  • Fluid pump and IV fluids prepared

Admission

The patient admission process involves many moving parts. A checklist can streamline and speed it up by including:

  • Confirmation of the procedure
  • Confirmation of surgical site and side
  • Patient was fasted
  • Owner’s address and phone number confirmed
  • Known allergies
  • Previous anesthetic complications
  • Current medications and supplements
  • Cardiopulmonary resuscitation (CPR)/do-not-resuscitate (DNR) status
  • Best number to reach the client
  • Social media authorization
  • Deposit taken
  • Consent form signed

Of course, this is assuming specific topics were clearly communicated during the pre-op consultation, including:

  • Description of the procedure
  • Expected outcome
  • Possible complications
  • Success rate
  • Diagnostics required pre-op
  • Estimate discussed, including all follow-up appointments
  • Home care
  • Medications
  • Dietary suggestions

Pre-op

Once a patient is admitted, surgery nurses need to do their magic. Their checklist can include:

  • Pre-op exam, including auscultation
  • Temperature, pulse, respiration (TPR)—without this simple information, you will not have a baseline to compare to during anesthesia
  • Preanesthetic bloodwork performed
  • Preanesthetic bloodwork reviewed
  • Premedication drugs calculated
  • Premedication drugs administered
  • IV catheter placed
  • IV catheter size and location noted
  • American Society of Anesthesiologists (ASA) score
  • Pain score (Check out my column “Why you should measure pain to improve pet patient care,” at bit.ly/3nseSY7)
  • Calculated emergency drugs
  • Pre-op fluids needs
  • Intra-op fluid rate
  • Endotracheal tube (ETT) cuffs checked and properly lubricated
  • Lidocaine for cat intubation
  • Laryngoscope prepared and tested
  • Confirmation of patient name
  • Confirmation of surgery site and side
  • Margins of clipping needed
  • Administration of antibiotics
  • Surgery instruments gathered

It is then important to have “surgery rounds” to decide on the best order of the procedures, confirm all the boxes were checked and nothing was omitted, and review any additional requirements.

Intra-op

Once the procedure starts, a checklist is yet again a simple way to ensure nothing was forgotten, including:

  • Anesthesia start time
  • Surgery start time
  • Fluid rate
  • Total volume of fluids administered
  • Endotracheal tube size
  • Anesthesia end time
  • Surgery end time

The anesthesia sheet itself contains another set of important information in the form of readings every five to 10 minutes:

  • Oxygen rate
  • Anesthetic gas rate
  • Heart rate
  • Respiratory rate
  • End-tidal CO2
  • Mean arterial pressure
  • Temperature
  • Fluid rate
  • Time of antibiotic injections
  • Need for post-op X-rays
  • Recovery cage prepared, with warming efforts if needed
  • E-collar ready

Post-op

Despite the common belief anesthesia is the riskiest part of surgery, it is during the post-op period that most complications occur. Post-op, patients should continue to be monitored, with vitals taken every five to 10 minutes until they become normal, then every two to four hours until discharge time. Your checklist should also direct staff to:

  • Assess pain score every two hours until discharge
  • Change the treatment plan as necessary
  • Dispense at-home medications

Discharge

When a patient is returned to their owner, many seemingly minor tasks should be thoroughly documented because in all honesty, nobody will remember the details of the encounter in a few days. This avoids the classic “he says, she says” argument when something goes wrong. Include the following:

  • Patient and incision cleaned
  • Paperwork and medications ready
  • IV catheter removed
  • Discharge instructions reviewed line by line
  • Discharge instructions signed by client and nurse
  • A final TPR is important, again to have a baseline
  • Pain score assessed, and pain medication injected if needed
  • Medication types, dosages, frequency, start times, and route reviewed with client

OR post-op

At the end of the surgery day, the OR needs to be turned around. Another checklist is helpful:

  • Sweeping, followed by mopping
  • Cleaning all surfaces
  • Pop-off valve open
  • Soda lime changed if needed
  • Supplies refilled (scrub, alcohol, gauze, eye lube, dry syringe)
  • Monitoring equipment turned off
  • Warming equipment turned off
  • Oxygen level checked
  • Anesthetic gas level checked
  • Suction and cautery cleaned and stored
  • Fluid pump turned off
  • Surgery laundry washed separately from general laundry
  • Cleaning, wrapping, and sterilizing surgery instruments

These checklists are merely a suggestion. They should be modified to fit your practice’s needs, including issues you may have encountered in the past. Checklists should not be static. They should evolve over time. Modify them as issues come up or unfortunate events unfold.

Once you are happy with your checklists as a team, you can rest assured the rate of mistakes should plummet. In fact, mistakes tend to happen when we don’t follow our checklists out of habit or hubris.

Checklists have been shown, in medicine and countless other fields, to decrease mistakes, reduce complications, and save lives. Implementing them, or improving yours, will dramatically increase client satisfaction, patient care, and team happiness.

Phil Zeltzman, DVM, DACVS, CVJ, Fear Free Certified, is a board-certified veterinary surgeon and author whose traveling surgery practice takes him all over Eastern Pennsylvania and Western New Jersey. You can visit his website at DrPhilZeltzman.com. He also is cofounder of Veterinary Financial Summit, an online community and conference dedicated to personal and practice finance (vetfinancialsummit.com). AJ Debiasse, a technician in Blairstown, N.J., contributed to this article.

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