The WHO Surgical Safety Checklist

To the Editor: The World Health Organization Surgical Safety Checklist (Checklist) has recently been editorialised by Merry and Barraclough.1 We are all keen to see perioperative mortality and morbidity reduced to a minimum, and one cannot disagree with the intent of the Checklist, which was tested in a pilot study2 involving almost 8000 patients in eight hospitals (in disparate developed and developing countries). The study showed a reduction in the death rate associated with surgery from 1.5% to 0.8% (or 15 per 1000 down to eight per 1000). Impressive indeed!

My concerns are firstly with process. One hospital in Brisbane has already introduced the Checklist without the constructive engagement of those at the clinical coalface, contrary to what proponents of the Checklist advocate, and it is being used in a way which distracts personnel during the induction of anaesthesia. To those familiar with accident analysis, this is a good example of poor process implementation by a hospital administration and its managers.

Secondly, I am concerned by the use of the study of Haynes and colleagues2 to underwrite the Checklist. Results of the study would be more meaningful if the reduction rates in mortality in the hospitals in the developed countries (Canada, United States, United Kingdom and New Zealand) were separated from those in the developing countries. Or would this have shown the developed countries’ reduction rate to be statistically non-significant? Are we to believe that use of the Checklist could save seven lives per 1000 procedures in Australia, or 15 000 to 21 000 lives across the three million procedures undertaken here annually? Total figures for perioperative mortality across all procedures in all operative categories remain a matter for conjecture. However, in looking at the high-risk group of cardiac surgical operations in Victorian public hospitals,3 we can see a published mortality rate of 10 per 1000 for coronary artery bypass or isolated valve surgery, only a little higher than that seen after the introduction of the Checklist across a broad surgical population.

We should be careful to see that spin does not become embedded within medicine, even where it is associated with what is probably a good idea.