Introduction of Surgical Safety Checklists in Ontario, Canada

BackgroundEvidence from observational studies that the use of surgical safety checklists results in striking improvements in surgical outcomes led to the rapid adoption of such checklists worldwide. However, the effect of mandatory adoption of surgical safety checklists is unclear. A policy encouraging the universal adoption of checklists by hospitals in Ontario, Canada, provided a natural experiment to assess the effectiveness of checklists in typical practice settings. MethodsWe surveyed all acute care hospitals in Ontario to determine when surgical safety checklists were adopted. Using administrative health data, we compared operative mortality, rate of surgical complications, length of hospital stay, and rates of hospital readmission and emergency department visits within 30 days after discharge among patients undergoing a variety of surgical procedures before and after adoption of a checklist. ResultsDuring 3-month periods before and after adoption of a surgical safety checklist, a total of 101 hospitals performed 109,341 and 106,370 procedures, respectively. The adjusted risk of death during a hospital stay or within 30 days after surgery was 0.71% (95% confidence interval [CI], 0.66 to 0.76) before implementation of a surgical checklist and 0.65% (95% CI, 0.60 to 0.70) afterward (odds ratio, 0.91; 95% CI, 0.80 to 1.03; P=0.13). The adjusted risk of surgical complications was 3.86% (95% CI, 3.76 to 3.96) before implementation and 3.82% (95% CI, 3.71 to 3.92) afterward (odds ratio, 0.97; 95% CI, 0.90 to 1.03; P=0.29). ConclusionsImplementation of surgical safety checklists in Ontario, Canada, was not associated with significant reductions in operative mortality or complications. (Funded by the Canadian Institutes of Health Research.) Public reporting of adherence to surgical safety checklists was mandated for all hospitals in Ontario, beginning in July 2010. In this study of administrative data, checklist introduction was not associated with significant reductions in operative mortality or complications. A study published in 2009 showed that implementation of the 19-item World Health Organization (WHO) Surgical Safety Checklist substantially reduced the rate of surgical complications, from 11.0% to 7.0%, and reduced the rate of in-hospital death from 1.5% to 0.8%.(1) The WHO estimated that at least 500,000 deaths per year could be prevented through worldwide implementation of this checklist.(2) This dramatic effect of a relatively simple and accessible intervention resulted in its widespread adoption. In the United Kingdom, a nationwide program was implemented by the National Health Service within weeks after publication of the WHO study,(3) and almost 6000 hospitals ...