Effectiveness of the Surgical Safety Checklist in Correcting Errors: A Literature Review Applying Reason's Swiss Cheese Model

Abstract

Approximately 2,700 patients are harmed by wrong-site surgery each year. The World Health Organization created the surgical safety checklist to reduce the incidence of wrong-site surgery. A project team conducted a narrative review of the literature to determine the effectiveness of the surgical safety checklist in correcting and preventing errors in the OR. Team members used Swiss cheese model of error by Reason to analyze the findings. Analysis of results indicated the effectiveness of the surgical checklist in reducing the incidence of wrong-site surgeries and other medical errors; however, checklists alone will not prevent all errors. Successful implementation requires perioperative stakeholders to understand the nature of errors, recognize the complex dynamic between systems and individuals, and create a just culture that encourages a shared vision of patient safety.

The Sequelae of Silence: Catheter Entrapment as a Preventable Morbidity Resulting from Communication Failure

“…slices of cheese) in which an error can pass and ultimately result in a severe complication. 11,12 However, as our case illustrates, even a single lapse in communication can have a potentially catastrophic effect.…”

Error Avoidance in Dermatologic Surgery

“…Incorrect surgical site identification results in approximately 2700 unnecessary patient injuries each year and is a leading cause for lawsuits among Mohs surgeons [12]. In an effort to reduce the frequency of wrong site identification, the Joint Commission published guidelines in 2004 that require preoperative site identification, visible marking of the site, and a "time out" before the procedure [13,14].…”

Patientensicherheit in der Shuntchirurgie

“…Für die USA wurde berechnet, dass es jährlich zu etwa 1'300-2'700 Eingriffsverwechslungen kommt [25]. Die chirurgische Checkliste ist ein wichtiges Instrument, um schwerwiegende seltene Ereignisse rechtzeitig abzuwenden, bevor Schaden entsteht [4]. Ob sie geeignet ist, die operative Mortalität und Morbidität systematisch und substantiell zu senken wird weiterhin kontrovers diskutiert [29].…”