The World Health Organization defines patient safety as the absence of preventable harm to a patient and the reduction of risk of unnecessary harm associated with healthcare to an acceptable minimum (WHO, 2008). It relies on an understanding that all staff, while committed to patient care, are nevertheless human and capable of making unintentional mistakes. Patient safety is, therefore, focused on identifying safety incidents and learning so the same error is not made again by a different operative (Rooke et al., 2021). It is important to remember that vets and nurses are human beings and, like all humans, are fallible.
Communication is central to improving patient outcomes, and checklists have been shown to improve this component of patient care across the medical and veterinary professions. Surgical safety checklists (SSCs) are an important tool in the perioperative period and paramount in maximising successful patient outcomes.
Patient safety in anaesthesia
Anaesthesia is a complex process that involves a series of critical steps that the clinical staff need to perform in a correct and timely manner. Despite being performed routinely and multiple times daily, anaesthesia is a multifaceted process that involves interactions between the patient, disease processes, drugs, equipment, procedures, the anaesthetist and the environment.
Anaesthesia should never be thought to be routine or straightforward. There is no room for complacency in anaesthesia, and each patient should have a patient-centred protocol in place. In fact, “there are no safe anaesthetic agents, there are no safe anaesthetic procedures, there are only safe anaesthetists”, according to Smith (1959).
There is no room for complacency in anaesthesia, and each patient should have a patient-centred protocol in place
The most appropriate anaesthetic protocol should consider the species, signalment, any concurrent diseases and the patient’s past responses to anaesthesia. Therefore, preparation and planning are integral to performing anaesthesia safely and effectively, and this involves more than just setting up equipment, calculating doses and drawing up and administering drugs.
The use of cognitive aids is advocated to minimise the risk of errors occurring during the perianaesthetic period. By using specific veterinary tools, such as SSCs, and recommended procedures during the perianaesthetic period, the team can openly communicate without reprimand to ensure patients remain as safe as possible.
Surgical safety checklists
SSCs are commonly used in high-risk undertakings and have had success in the aviation and construction industries. Following the Safe Surgery Saves Lives campaign, they were introduced to human operating theatres as a tool to reduce the risk of preventable complications during the perioperative period (WHO, 2008). They have been largely successful in reducing incidents in the human field.
These checklists are a list of actionable tasks crucial to the performance of a process. Each task must be completed before moving on to the next stage and should involve all members of the team to ensure engagement and compliance.
SSCs are designed to eliminate the need to memorise every step of a protocol, thereby limiting any errors that may lead to fatal or near-fatal incidents. They are also intended to facilitate effective communication and improve collaboration on the delivery of patient care and should be used to identify patient risks before surgery so strategies can be discussed and implemented to minimise any risk to patients and staff (Mayer and Shepard, 2016).
Studies have reported significant improvements in surgical outcomes with the use of SSCs: a potential 47 percent reduction in deaths, 36 percent reduction in post-operative complications and 48 percent reduction in infections (Bergström et al., 2016; Haynes et al., 2017; Mehta et al., 2018). Feedback from teams using the WHO SSC indicated that 78 percent of respondents believed the checklist had prevented an error (Haynes et al., 2009; Fudickar et al., 2012).
Anaesthetic safety checklists can improve patient safety, ensure critical steps have been performed prior to anaesthesia and improve communication and collaboration between team members
Performing anaesthetic safety checks is paramount in maximising successful patient outcomes and preventing exposure of volatile agents to staff. The Association of Veterinary Anaesthetists developed a safety checklist with the aim to increase awareness and reduce human error to improve patient safety in anaesthesia. This checklist helps ensure the anaesthetic machine and breathing system are in good working order and safe before inducing the patient.
Anaesthetic safety checklists can improve patient safety, ensure critical steps have been performed prior to anaesthesia and improve communication and collaboration between team members (McMillan, 2014).
How do surgical safety checklists work?
Anaesthesia and surgery checklists introduce three focused periods of pausing and patient detail checking before proceeding to the next stage of the procedure. These three stages include the points considered the most crucial in a surgical procedure and represent stages where missing a step could have the most significant consequences.
The three stages are:
- Prior to induction of anaesthesia – “sign in”
- Prior to the procedure beginning (eg before the first surgical incision is made) – “time out”
- Prior to recovering the patient – “sign out”
Sign in
The first part of the checklist is the “sign in” stage which should be completed before induction so any issues that could prevent anaesthesia are discussed. It covers items such as anaesthetic machine checks, airway risk, blood loss estimations and ensuring the correct patient is present.
Time out
The “time out” stage is completed before the first incision. It is when the surgical team pauses to fill out the SSC and focus on the patient.
It covers the critical steps required to prevent adverse events, and each item should be read aloud and verbally confirmed by the team in the room. The team should communicate their specific concerns regarding the procedure and anaesthetic, including fluid therapy plans, perioperative analgesia and expected blood loss. During this stage, the equipment sterility and availability are verified, the patient and surgery site are confirmed and swabs are counted in.
Sign out
At the end of the procedure, all instruments, needles and swabs must be accounted for and recorded. The team should communicate post-operative concerns, plans and any adverse events. This forms the “sign out” section of the checklist.
How do I implement surgical safety checklists in my practice?
The introduction of SSCs can come up against resistance, with a fear of change often expressed by staff who feel it is unnecessary. This is usually a short-lived response, with the majority eventually embracing its use.
You should design an SSC to engage with the entire team and encompass the most important aspects of your practice’s concerns and the patient’s needs. A single checklist is therefore unlikely to suit all practices, but following introduction, they are easily adapted to ensure maximum benefit and team compliance.
Conclusion
A structured and organised approach to the assessment and preparation of the patient, drugs, equipment and veterinary team can make a critical difference in patient safety. Safe anaesthesia is achievable in all practices without being overly expensive and time-consuming. Therefore, cognitive aids such as checklists can help even the most experienced anaesthetists provide safer anaesthesia.
[Surgical safety checklists] may make the difference in successfully dealing with an emergency and preventing patient harm
While it is well accepted that carrying out anaesthetic and surgical procedures in patients is not risk-free, the use of SSCs can help ensure perioperative preparation is thorough and that specific patient factors are taken into consideration. It may make the difference in successfully dealing with an emergency situation and preventing patient harm!
