Neurosurgery Evaluates Use of Checklists

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Many surgical specialties have embraced use of a checklist as a means of improving patient safety, but the literature on its uptake and effectiveness in neurosurgery is sparse, researchers found.

The field has “only minimally addressed the utility of checklists as a healthcare improvement measure,” Scott Zuckerman, MD, of Vanderbilt University, and colleagues reported in a review published in a special issue of Neurosurgical Focus dedicated to surgical error and risk mitigation.

Atul Gawande, MD, of Harvard, who has long championed surgical checklists in books and articles in The New Yorker, echoed those sentiments in a podcast produced by the journal.

“Neurosurgery struggles with the fact that in any given institution, even in high volume centers, volumes are still low enough for any given procedure that it’s very difficult to see patterns of why failures occur,” Gawande said. “What you see coming out of reviews is some suggestive evidence, but … it’s predominantly single-institution studies and you’re peering into the tea leaves at the bottom of the tea cup and trying to read the patterns.”

Gawande added that there’s “no collective effort to gather information more broadly.”

The special issue includes 16 articles on quality improvement for neurosurgical disorders. James Forrest Calland, MD, of the University of Virginia — one of four editors on the special issue — noted that the studies fall into four categories: improving pre-, intra-, and postoperative processes; validating tools such as checklists in neurosurgical settings; clinical and environmental issues; and subspecialty-specific issues.

In one review, Judith Wong, MD, MPH, of Harvard, and colleagues, made five recommendations to reduce adverse events in neurosurgery:

• Adopt the World Health Organization surgical safety checklist in the neurosurgical operating room
• Build a national registry for outcome data and monitoring
• Standardize specialized equipment to diminish adverse events due to technology or hardware
• Increase subspecialization and regionalization of care
• Establish evidence-based guidelines and protocols

In addition to checklists, other strategies for improving safety include time-outs and debriefings. Agi Oszvald, MD, of Johann Wolfgang Goethe University in Frankfurt, Germany, and colleagues, found in early data that adding a time-out to their surgical checklist diminished errors.

Their team implemented a checklist in 2007, and added the time-out procedure in 2011. Out of 8,795 procedures between January 2007 and December 2010, there was one wrong-sided burr hole in an emergency case and one wrong-sided lumbar approach in an elective case.

Once the time-out was implemented, there were no errors in 2,595 procedures between January 2011 and June 2012, they reported.

They also found the number of incomplete checklists was significantly lower after implementing the advanced checklist with the time-out, they reported (P=0.002).

Zuckerman and colleagues reviewed the literature on surgical debriefing and reported their institutional experience with the process.

Overall, the literature on this procedure “has yet to definitively link debriefing with reduced rates of morbidity and mortality,” but it has shown diminished error rates and improvement in team communication, they wrote.

But the literature on debriefing in neurosurgery specifically, they cautioned, is very limited.

To be effective, they added, surgical debriefings should be conducted soon after a procedure, with all team members involved.

PT Screening

Stephan Dutzmann, MD, of Johann Wolfgang Goethe University in Frankfurt, and colleagues assessed whether preoperative assessment of prothrombin time (PT) is mandatory in patients having routine neurosurgical procedures.

They conducted a retrospective review of the charts of 4,310 patients who had a planned surgery between 2006 and 2010.

Overall, 33 patients, or 0.7% of the total population, had hemorrhagic complications that required repeat surgery.

The majority of these patients (94%) had normal PT before the initial operation, while two had slightly elevated PT values, which was anticipated based on history, the researchers said.

Preoperatively, PT was elevated in 77 patients (1.8%). In 72 of these (93.6%), PT elevation was explained by medical history.

Unexpected PT elevation occurred in only 0.1% of patients. All of these had surgery without complications, while two had coagulation factor substitution preoperatively. None received coagulation after the operation.

The researchers saw no significant association between preoperative elevated PT levels and hemorrhagic complications — a finding that suggests the “value of preoperative PT testing is limited in patients in whom a normal history can be ascertained.”

They noted that postoperative PT control is necessary in all patients, and researchers need better tests to identify those at risk of hemorrhagic complications.

Surgery Specific Evaluations

The special issue also includes reports on surgical time-outs and checklists in specific areas, including intra-operative neuromonitoring changes and in the intra-operative MRI suite.

Four studies looked at patterns of adverse events in four areas of neurosurgery: cerebrospinal fluid shunt surgery, endovascular neurosurgery, open cerebrovascular neurosurgery, and intracranial neoplasm surgery.

And an Italian team led by Paolo Ferroli, MD, of the Fondazione Instituto Neurologico in Milan, found that implementing an aviation checklist for incident reporting helped identify reasons for surgical errors.

Among 14 near-misses, human factors played a role in 9 cases, organizational factors in 3 cases, technology in one case, and procedural factors in another, they reported.