Study shows introduction of surgical safety checklists in Ontario have not reduced post-operative mortality or complications

The introduction of surgical safety checklists in Ontario hospitals did not improve operative mortality, according to a population-based study by researchers at the Institute for Clinical Evaluative Sciences (ICES), University Health Network (UHN) and St. Michael’s Hospital.

The study “Introduction of Surgical Safety Checklists in Ontario, Canada” published today in the New England Journal of Medicine, examined the effectiveness of surgical checklists. The Ministry of Health and Long-Term Care (MOHLTC) mandated public reporting of surgical safety checklist adherence for hospitals beginning July 2010.

“Our study did not demonstrate the striking improvement in patient outcomes identified in previous studies. While a greater effect of surgical safety checklists might occur with more intensive team training or better monitoring of compliance, as currently implemented, surgical safety checklists did not result in improved patient outcomes,” said Dr. David Urbach, co-lead author, staff surgeon at UHN and adjunct scientist at ICES.

In the study, researchers analyzed the outcomes of surgical procedures three months before and three months after adoption of surgical safety checklists at 101 hospitals in Ontario. Adjusted mortality was 0.71 per cent before and 0.65 per cent after introduction. Checklist use did not result in an improvement in surgical complications, emergency department visits or hospital readmissions within 30 days of surgery. There was a statistically significant but small and not clinically relevant reduction in adjusted length of hospital stay (5.11 days before and 5.07 days after).

“These results were very unexpected in light of the findings of other recent studies examining the impact of surgical checklists,” said Nancy Baxter, co-lead author, scientist in the Keenan Research Centre of the Li Ka Shing Knowledge Institute of St. Michael's Hospital and adjunct scientist at ICES.

Ontario hospitals implemented surgical checklists between June 2008 and September 2010, in response to the plan of the MOHLTC to publicly report compliance with use of the checklist. Self-reported compliance—the percentage of surgeries in which a surgical safety checklist was used, as reported in each hospital by a person such as an operating room nurse—by all hospitals in the province is high: 92 per cent in April—June 2010, and never less than 98 per cent after July 2010.

“While there may be value in the use of surgical safety checklists, such as enhanced communication and teamwork, and the promotion of a safety culture, these benefits did not translate into meaningful improvements in the patient outcomes that we analyzed in this study,” adds Baxter.

Authors: David R. Urbach, Anand Govindarajan, Refik Saskin, Andrew S. Wilton and Nancy N. Baxter.

ICES is an independent, non-profit organization that uses population-based health information to produce knowledge on a broad range of healthcare issues. Our unbiased evidence provides measures of health system performance, a clearer understanding of the shifting healthcare needs of Ontarians, and a stimulus for discussion of practical solutions to optimize scarce resources. ICES knowledge is highly regarded in Canada and abroad, and is widely used by government, hospitals, planners, and practitioners to make decisions about care delivery and to develop policy.

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