Optimizing timing of completion of the Surgical Safety Checklist to account for emergence from anesthesia.

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Date: May 9, 2022
From: CMAJ: Canadian Medical Association Journal(Vol. 194, Issue 18)
Publisher: CMA Impact Inc.
Document Type: Article
Length: 1,779 words
Lexile Measure: 1850L

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As part of the "Safe Surgery Saves Lives" initiative, the World Health Organization (WHO) launched the Surgical Safety Checklist (SSC) in 2008, aiming to address important surgical safety issues and poor communication among operative team members. (1) In 2009, the Canadian Patient Safety Institute (CPSI) used the WHO SSC as a basis for its own 19-item SSC that would best fit Canadian standards of care and lay the groundwork for local practices (2) (available at https://www.patientsafetyinstitute.ca/en/toolsResources/ pages/surgicalsafety-checklist-resources.aspx). Between January and June 2021, 98.5% of surgeries in Ontario reported having completed the checklist. (3) While surgical checklists have undoubtedly improved the safety of surgeries, the SSC misses a key component of the surgical continuum because it is completed before the patient leaves the operating room. We propose an additional checklist item to cover emergence from anesthesia and further increase patient safety.

The SSC was adapted from checklists used in the airline industry. Pilots complete a series of checklists throughout several phases of a flight, including preflight, take-off, approach and landing. These phases are analogous to the phases set out in the SSC. Similar to the preflight phase, the "sign-in" or "briefing" checklist is completed when the patient enters the operating room before induction of anesthesia, where the patient's identity, surgical procedure and site of incision are confirmed. The "timeout" phase occurs immediately before the incision is made and is analogous to the taxiing and take-off phase in a flight checklist, as it is the final opportunity to review the site and planned procedure and anticipate critical events. The final phase, "sign-out" or "debriefing," corresponds to the landing phase of a flight, occurring when or before the patient leaves the operating room. (1) The sign-out stage comprises a review of the procedure, important intraoperative events, fluid management, instrument counts, specimen labelling and management, and recovery plans, including postoperative ventilation, pain management and temperature. (2) This phase includes 3 final questions: "Changes to the postoperative destination?," "What are the key concerns for this patient's recovery and management?" and "Could anything have been done to make this case safer or more efficient?." (2)

The sign-out phase should be completed "before the patient leaves the operating room." (1,2) Unlike the sign-in and time-out phases, where the timing of completion is clear, definitive and anchored to a specific clinical moment in time, sign-out can be completed any time before the patient leaves the operating room--even before emergence from anesthesia. This creates the potential for poor communication of critical events during a patient's emergence from anesthesia.

The risks of anesthetic complications are greatest at the final phase of anesthesia. (4,5) Signing out before the patient fully emerges from anesthesia is akin...

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Gale Document Number: GALE|A703277330