World J Surg DOI 10.1007/s00268-014-2464-8

How Should Surgical Safety be Taught? Rahul Prashanth Ravindran Sayinthen Vivekanantham



Ó Socie´te´ Internationale de Chirurgie 2014

We thank Saturno et al. [1] for highlighting issues surrounding compliance with the World Health Organisation Surgical Safety Checklist (WHO SSC) [2]. The authors suggest that checklist compliance would ‘‘improve with overall safety culture improvement,’’ which should be ‘‘an objective that should be explicitly considered in all training programs for residents and health professions curricula.’’ We welcome this suggestion; however, we would like to raise certain points to be aware of surrounding educating medical trainees on safety checklists. Checklists may be effective as a result of our colleagues being able to scrutinize the document, similar to the Hawthorn effect discussed in the study by Saturno et al. [1]. However, no research has been carried out to determine whether tasks that are not being monitored as part of a checklist, or with low compliance, will be conducted to a compromised standard when checklists are in use. Indeed, Rydenfa¨lt et al. [3] suggest that when checklist compliance is low (as demonstrated by Saturno et al. [1]), in combination with other safety checks being omitted because team members think they are being handled by the checklist, a false sense of safety will arise. For example, the checklist asks whether the pulse oximeter is functioning before the induction of anesthesia, but there is no specific question regarding the fluid status of the patient [2]. Perhaps the younger generation of trainees may neglect the importance of other key parameters simply because it is not on this list, especially in the acute setting. Whilst the initial WHO guidelines for safe surgery state that ‘‘checklists clarify the minimum expected steps in a complex process,’’ [4] the numerous checklists that have

been created may result in the junior trainee relying on these aids. This poses the risk of trainees feeling that checklists are sufficient to assure safety, rather than a minimum standard. Currently, doctors in training are already taught and assessed on a number of guidelines and protocols. Although we agree that careful implementation of these guidelines can improve medical safety by means of reduced complication rates, [2] we fear that being taught about more checklists in the clinical setting may introduce challenges in usage. Indeed, ‘checklist fatigue’—where the overuse of checklists results in reduced overall compliance—is increasingly recognized in clinical contexts [5]. We believe the study by Saturno et al. [1] clearly highlights that education on medical safety must increase; however, in the context of checklists we should reinforce that they are a minimum standard rather than the benchmark. If the emphasis of safety education is focused on checklists, then trainees may not equip themselves with the necessary skills and knowledge to approach novel clinical scenarios with confidence. We welcome further teaching on the importance of checklists in the surgical safety curriculum; however, as the low compliance in the study by Saturno et al. [1] demonstrates, we believe that future educators must emphasize the rationale behind checklists, and stress that checklists are only one component in improving the culture of patient safety. Conflict of interest

None declared.

References R. P. Ravindran (&)  S. Vivekanantham Faculty of Medicine, Imperial College London, London, England e-mail: [email protected]

1. Saturno PJ, Soria-Aledo V, Da Silva Gama ZA, Lorca-Parra F, Grau-Polan M (2014) Understanding WHO surgical checklist implementation: tricks and pitfalls. An observational study. World J Surg 38(2):287–295

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World J Surg 2. Haynes AB, Weiser TG, Berry WR et al (2009) A surgical safety checklist to reduce morbidity and mortality in a global population. N Engl J Med 360(5):491–499 3. Rydenfa¨lt C, Ek A, Larsson PA (2013) Safety checklist compliance and a false sense of safety: new directions for research. BMJ Qual Saf 22(11):881–884

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4. World Health Organization (2009) WHO guidelines for safe surgery. World Health Organization, Geneva 5. Hales B, Terblanche M, Fowler R, Sibbald W (2008) Development of medical checklists for improved quality of patient care. Int J Qual Health Care 20(1):22–30

How should surgical safety be taught?

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