Check a Box. Save a Life. - Safesurg.org€¦ · Save a Life” campaign can make a tangible...

Check a Box. Save a Life. The First Global Student Sprint to Improve Health Care.

Student Improver’s Handbook Prepared By:

The “Check a Box. Save a Life.” Team

Check a Box. Save a Life. Student Improver’s Handbook,

Contact us at: [email protected]

Table of Contents

I. Executive Summary 3

II. Call to Action 4

III. Background: WHO Safe Surgery Saves Lives Program 5

IV. How You Can Get Involved

A. Raising Awareness

B. Collecting Data

C. Working with Clinicians to Bring the Checklist to a Hospital

6

V. Conclusion 13

VI. Authors and Contributors 14

VII. Appendices

A. WHO Surgical Safety Checklist

B. WHO Surgical Safety Checklist Resources

C. Letter to Mentor/Advisor

D. Data Collection Sheet

E. Case Study Template

15

16

19

20

21



Executive Summary

In June 2008 the World Health Organization (WHO) launched an exciting new initiative to improve the safety of surgical care worldwide. Their tool, a one page, 19-item Surgical Safety Checklist, was later shown to reduce complications and deaths from surgery by more than 30% in an eight site global pilot study. The incredible potential of the Checklist to improve patient care and save lives cannot be realized if the Checklist is not put into the hands of frontline clinicians and used in the more than 230 million operations performed every year.1 Students, although often unable to affect change directly, can use the incredible power of their social networks to spread the Checklist and help improve patient safety around the world. This handbook is designed to show you how to do this successfully. The “Check a Box. Save a Life.” Campaign is your opportunity to take a proven, life-saving, evidence-based tool to patients in the hospitals where you are learning and practicing today. We hope that these materials are useful to you. Please send your thoughts and feedback about the “Check a Box. Save a Life.” Student Improver’s Handbook to our email address: [email protected]. We count on your feedback to help improve this initiative and the safety of surgical patients everywhere.

1 Weiser T.G., et al. An estimation of the global volume of surgery: a modeling strategy based on available data. The Lancet, 2008: 372:139-144.



Call to Action

The “Check a Box. Save a Life.” campaign is the first global initiative designed to improve health care by harnessing the incredible potential of students. As relative newcomers to the field, students can be extremely powerful agents of health care improvement – they are better equipped to identify problems in the system because they have not yet been contaminated by it. This initiative will help students like you take advantage of your incredible power to improve surgical safety by working to spread the WHO Surgical Safety Checklist across the globe. In order to make this initiative a success, we need to actively use the resources already available to us. As students who are limited by the rigid hierarchical structure of health care, our strongest asset is our social network. Family members, friends, colleagues, and mentors are excellent advocates for promoting patient safety projects. By spreading knowledge within these networks, we can increase awareness about surgical safety at an exponential rate. We ask you to speak to everyone you know who works in health care about the Checklist and how it can improve surgical care. By doing so, you can not only help to spread the Checklist to your contacts’ hospitals, but you can also raise awareness as your contacts pass this knowledge through their social networks, as well. The materials in this Student Improver’s Handbook are meant to serve as a how-to-guide for students to promote the use of the WHO Surgical Safety Checklist. After reading these materials, please make a list of all of the people in your immediate network that would be interested in using the Checklist or that have connections to people in the health care field. You may be surprised by all of the opportunities that are available through the people you already know. Thank you for your enthusiasm and good luck!



Background: WHO Safe Surgery Saves Lives Program

While surgical procedures are intended to save lives, unsafe surgical care can cause substantial harm. Infections and other postoperative morbidities are also a serious concern around the world. The World Health Organization’s Surgical Safety Checklist was created by an international group of experts gathered by the WHO with the goal of improving the safety of patients undergoing surgical procedures worldwide. Input from anaesthetists, operating theatre nurses, surgeons, patients, and other professionals were used in the development of this tool.

The Checklist identifies three phases of an operation, each corresponding to a specific period in the normal flow of work: before the induction of anaesthesia, before the skin incision, and before the patient leaves the operating theatre. Each of the 19 items included on the Checklist is based on clinical evidence or expert opinion and has been included on the Checklist because of its likelihood to reduce serious avoidable harm. Many of these items are routine practices in hospitals throughout the world, although they are rarely undertaken in their entirety. The Checklist is intended to be used as a verbal aid to ensure that the surgical team completes each safety check and to encourage each member of the surgical team to address any safety concerns aloud. The Checklist is therefore intended to be read aloud to the team by a designated team member.2 The Checklist has been tested in a multi-site pilot study with results published in the New England Journal of Medicine in January 2009. In sites that ranged from a small district hospital in rural Tanzania to a large medical center in the United States, the use of the WHO Surgical Safety Checklist was demonstrated to reduce the complications and mortality associated with a variety of surgical procedures by more than 30%.3 Since the release of the study results, hospitals and government organizations throughout the world have started using the Checklist. As of January 2010, more than 3,500 hospitals representing more than 120 countries have started using this tool in their operating theatres, with more than 21 countries mobilizing resources to implement the Checklist at a national level. For more information about the WHO Surgical Safety Checklist or the Safe Surgery Saves Lives program please visit www.safesurg.org and www.who.int/safesurgery or refer to Appendix B for a list of the numerous resources published by the WHO Safe Surgery Saves Lives program.

2 WHO Implementation Manual, 2009. http://www.safesurg.org/implementation-manual.html 3 Haynes, A.B., et al. A Surgical Safety Checklist to Reduce Morbidity and Mortality in a Global Population. NEJM, Jan., 2009: 360:491-499.



How You Can Get Involved

Although the WHO Surgical Safety Checklist holds great potential for reducing perioperative morbidity and mortality worldwide, this potential will never be realized if the Checklist is not used on a large scale or in the intended way. Since the launch of the Checklist in 2008, it has rapidly spread to hospitals throughout the world. While we have made tremendous strides in spreading the Checklist, we still have a long way to go. By coupling the promise of the Checklist to save lives with the potential of students to spread the Checklist through our social networks, the “Check a Box. Save a Life” campaign can make a tangible difference in patient safety across the globe.

Although the rigidly hierarchical structure of today’s hospitals means that many students may not feel empowered to influence organizational policies, we can still leverage our unique roles as students to improve the lives of our patients. Students’ most powerful tools are often the people that they know. Every person in the world has family, friends, colleagues, and mentors that know people that work in health care and can directly improve patient safety. These are the people who can enable you to effectively change patient care. The “Check a Box. Save a Life.” campaign is designed to provide the support and resources to allow you to do just that. Below is a detailed description of three ways you can leverage your social networks to make a difference in the lives of surgical patients. We have included case studies in each section to illustrate how students, like you, have been successful in these endeavors in the past. 1. Raising Awareness Over 700,000 medical journal articles are published each year.4 Given this large volume of information, it is not surprising that it takes on average 17 years for new evidence-based findings to reach clinical practice.5 Thus, one of the most important contributions students can make is to draw clinicians’ attention to the WHO Surgical Safety Checklist and the results of the pilot study published in the January 2009 edition of the New England Journal of Medicine. It is likely that there are many hidden checklist supporters who would enthusiastically join the movement to improve surgical safety if they only knew about it.

4 National Library of Medicine. “Key Medline Indicators,” November 12, 2008, accessed at www.nlm.nih.gov/bsd/bsd_key.html. 5 Balas EA, Boren SA. Managing clinical knowledge for health care improvement. In: Bemmel J, McCray AT, editors. Yearbook of Medical Informatics 2000: Patient-Centered Systems. Stuttgart, Germany: Schattauer Verlagsgesellschaft mbH; 2000:65-70.



Raising awareness amongst those who can directly impact patient care: The most direct way to achieve this awareness is to present the Checklist and some basic background materials to anyone you know who might be able to introduce the Checklist to his or her institution. This includes surgeons, anaesthetists, operating theatre nurses, and administrators. To begin this process, we suggest that you reach out to your contacts with an initial email, letter, or phone call. In this first correspondence you want to briefly describe the project and its potential impact on surgical care and request an opportunity to meet with them to discuss the project further. In Appendix C, we have included a template letter that you can use to reach out to your contacts, but we encourage you to modify its tone and content each time you send it. For example, such a formal letter should not be sent to an uncle you see frequently and know well, but may be appropriate to send to an academic advisor you are not as familiar with. If your contact is receptive to discussing the project further we suggest that you set aside at least 30 minutes with them and that you bring a number of Checklist resources with you to the meeting. The “Speakers’ Kit/Introductory PowerPoint” can be a useful tool to guide your presentation of the Checklist, but, again, it may need to be tailored to your audience and environment. Other resources that can provide guidance at this initial stage include:

□ WHO Surgical Safety Checklist □ The New England Journal of Medicine article □ Frequently Asked Questions □ Implementation Manual □ Checklist Demonstration Videos

If your contacts are interested in learning more and/or in implementing the Checklist at their institutions, please point them towards the Safe Surgery Saves Lives websites (www.safesurg.org; www.who.int/safesurgery) and encourage them to explore the other resources that are available there. By utilizing the list of resources in Appendix B, you can continue to serve as their guide by connecting them with appropriate materials as they move forward with this project.



Example: An MPH student working in Boston learned about the WHO Surgical Safety Checklist and decided to help spread it as part of her practicum. Although her immediate family lives in the United States, she has some extended family and friends in India who are well connected in the medical field. Over the course of a few weeks, she reached out to each of these individuals by email and scheduled subsequent phone conversations to tell them more about the Checklist and ask if they would be interested in getting involved in this global health initiative. Four of these contacts agreed, so she sent them a number of implementation resources and showed them how to register as a participating hospital on the WHO website. These contacts not only succeeded in implementing the Checklist in their hospitals, but they also raised awareness about the Checklist amongst their colleagues across India.

Raising awareness amongst your peers: If you do not personally know someone who is able to directly implement the Checklist in an institution, you can still play an important role in raising awareness and spreading the Checklist. Although not all students are connected to surgeons, administrators and the like, all students are connected to other students, and by raising awareness amongst your peers and amongst students in other health professions, you will still be making a substantial contribution to the overall well being of future patients. If even one of these students is inspired to spread knowledge of the Checklist to someone who is able to put it in place in a hospital, the success is yours as well.

There are a number of ways to raise awareness amongst your peers. One way is to host a lunchtime talk about the Checklist sponsored by a relevant student group — for example, the Institute for Healthcare Improvement (IHI) Open School for Health Professions, the American Medical Student Association, or other student organizations. If no such group exists on your campus, you could start one and use the “Check a Box. Safe a Life.” campaign as your first effort. Some less formal, but equally important, strategies include emailing relevant list-servs and having personal conversations with peers you think might be interested in the project.



Example: Students at a School of Public Health recognized a growing interest amongst their peers in quality improvement and patient safety and decided to form a student group centered on this issue. Called QIPS (Quality Improvement, Patient Safety), the group met periodically and charged itself with the mission “to foster commitment and advance preparation of the next generation of professionals across disciplines to improve the quality and safety of health care locally, nationally, and globally.” When one of its members learned about the Checklist, she organized a lunchtime meeting to present the program to her fellow members. She ordered pizza, sent out invitations by email, and put up posters in the days leading up to the event. She reworked the “Speakers’ Kit/Introductory PowerPoint” to fit her needs and presented it to the group. She passed out copies of the Checklist to all that attended and encouraged them to get in touch with her if they were interested in pursuing the project further. A number of her classmates did just this and many went on to spread awareness of the Checklist to their friends and family.

2. Collecting Data Another way that you can impact surgical safety is by collecting data. Data can help make the case for using the Checklist if clinicians initially see it as unnecessary. One of the most common responses to the Checklist is, “But we already do that.” The Checklist, however, was based on the premise that while clinicians may always intend to accomplish each safety check included on the Checklist, in reality steps are missed from time to time. Indeed, during the period of baseline data collection in the WHO pilot study, at least one of the six key safety steps being monitored was missed in two out of every three cases.6 Even in the most advanced hospitals in the developed world, key safety checks were not performed 100% of the time. By collecting baseline data at your hospital, you can provide the necessary information to counter skeptics’ claims that the Checklist isn’t necessary or wouldn’t improve patient safety. People at your hospital will be much more willing to use the Checklist if you can prove that there is progress to be made; furthermore, they will be much more likely to continue to use the Checklist once it has been implemented if you can prove that using it is making real and significant differences in the health outcomes of patients. To do this, you will need data telling you where you have started in order to later evaluate how much you have improved. 6 Haynes, A.B., et al. A Surgical Safety Checklist to Reduce Morbidity and Mortality in a Global Population. NEJM, Jan., 2009: 360:491-499.



The easiest way to successfully collect data in a hospital is to partner with an already existing data collection campaign – something best achieved by leveraging your personal connections. Let these individuals know of your interest in conducting such a study and ask if any would be willing to sponsor your efforts. Although we recognize that this is not always possible, we strongly caution you not to launch an independent data collection effort unless your hospital has a culture that would be amenable to such student involvement. Before beginning any data collection effort you should advise the appropriate clinical and hospital leaders of your intention and secure all necessary permissions. Once you have received permission to proceed, use the sample data form in Appendix D to collect data for a month. We recommend that you collect data on at least 50 cases to ensure that your data accurately represent your hospital’s baseline practices. Using the data you have collected, identify potential areas for improvement (for example, in only 57% of our procedures are patients receiving appropriately-timed antibiotics) as well as data that tells you that you are doing well in a certain area (in 100% of our cases, sterile instruments are being used). If this data is based on a reliable data collection technique and if it is presented to hospital leadership in an appropriately respectful way, it may be just what is needed to convince skeptics of the value of the Checklist.

Example: The Wales Chapter of the IHI Open School for Health Professions created a framework for collecting and disseminating data to encourage Checklist implementation through the previously established 1000 Lives Campaign. The Wales Chapter relied heavily on the 1000 Lives Campaign’s Director, Professor Jonathon Gray, to establish the necessary links with surgical content area specialists, the CEO of the National Patient Safety Agency, and the Quality Improvement Board at the Welsh Assembly Government. Professor Gray also served as the group’s guarantor when they approached senior surgical faculty in the School of Medicine, Cardiff University. The Wales Chapter then approached the Student Surgical Society at Cardiff and invited them to collect data on each surgical case they observed. Students were asked to report after each surgery whether 5 key processes included on the WHO Surgical Safety Checklist and already considered “standard protocol” were successfully performed. In the first three months of the program, surgical students at Cardiff University submitted online data forms for 83 operations and helped to identify areas for improvement (in 37% of cases the timing of the prophylactic antibiotics was not verified) and areas where they were already doing well (the needle and instrument count was completed in 96% of all cases).



3. Working with Clinicians to Bring the Checklist to a Hospital

If after making your initial contact with members of your social network they are interested in bringing the Checklist to their hospital, you can continue to play an integral role in this process. However, a note of caution: if you do not involve a sufficient number of hospital personnel in your efforts, there will not be adequate buy-in from frontline workers to ensure that the program is sustained over time. Although you are your contacts’ local Checklist expert and can help them to successfully introduce this tool to their hospital, this is a collaborative effort and you should not do this on your own. One of the most important things that you can do at this stage is to ensure that the proper preparations are made before the Checklist is used in operating theatres. Some steps that you might want to consider taking include:

□ Collect baseline data □ Recruit leaders from all relevant disciplines (surgery, anaesthesia, nursing,

and administration) □ Translate the WHO Surgical Safety Checklist into the local language/dialect □ Work with clinicians to modify the Checklist to meet local needs □ Work with clinicians to trial the Checklist in one operation (and to further

modify the Checklist as necessary after each trial) □ Help train all relevant personnel (surgeons, anaesthetists, nurses, technicians,

etc.) □ Develop a strategy for expanding the use of the Checklist within the facility

(i.e., we encourage facilities to start testing the Checklist on a small scale and then expand its use over time)

Although enthusiastic leaders may be tempted to simply distribute copies of the Checklist to every operating theatre overnight, Checklist use should only be expanded to all operating theatres after each of these steps has been accomplished. You can be pivotal in helping local leaders realize the importance of these preparations and ensure that they are successfully accomplished. Based on the experiences of the thousands of hospitals that they have worked with since July 2008, the Safe Surgery Saves Lives program has developed numerous materials to guide and facilitate the process of introducing the Checklist to hospitals in all settings. One of the most important things that you can do as a facilitator is to read the Safe Surgery Saves Lives documents and communicate their messages to your counterparts. By investing the time necessary to read and fully absorb all of the materials available, you can ensure that the introduction of the Checklist at your hospital proceeds as smoothly as possible and that key steps are not overlooked.



Resources that will be important to examine at this stage include:

□ Implementation Manual □ Starter Kit □ Checklist Adaptation/Modification Guide □ Checklist Demonstration Videos □ Frequently Asked Questions □ The New England Journal of Medicine article

**Even if you do not feel that you have enough time to be directly involved in the implementation process, you can contribute to its success by encouraging your hospital to register with the WHO: http://www.who.int/patientsafety/safesurgery/hospital_form/en/index.html. By submitting your hospital’s contact information, you will connect them with the Safe Surgery Saves Lives Dissemination Team, whose representatives can assist remotely in the implementation process if you are unable to do so yourself.**

Example: Inspired by the Checklist work and in search of a project for her practicum, an MPH student decided to take the WHO Surgical Safety Checklist to Pakistan, where many of her family members live. She made plans to visit Karachi over her winter break and identified three academic institutions in the city where she had personal contacts through her family. These contacts introduced her to a variety of hospital leaders, and she met with each of them to personally present the benefits of using the Checklist. At one of the three hospitals, the leader was so interested in the program that he committed to implementation on the spot and asked her to help them during her remaining time in town. He arranged for her to present the Checklist to an audience of surgical residents and faculty and encouraged her to coordinate a trial of the Checklist in three operating theatres. She helped local staff translate the checklist into Urdu and then joined them in the operating theatre to answer questions and demonstrate how the Checklist can be incorporated into normal workflow. After she left Karachi and returned to the U.S., she used email and telephone communication to stay in touch with the hospital leader left in charge of Checklist implementation, offering advice, answering questions, and ensuring that Checklist use did not wane in her absence.



Conclusion Although the WHO Surgical Safety Checklist holds great promise to positively impact the lives of thousands of patients worldwide, we cannot realize this potential without your help. As students, we have the unique power to contribute to this important effort by spreading awareness through our social networks. We should not let the rigid hospital hierarchy prevent us from positively affecting patients’ lives. By using the tools and techniques outlined in this document we do not have to wait; we, as students, can make a difference now. As you move forward, please stay in touch. We want to hear about your progress so we can share your stories with others and learn from both your successes and any barriers you may have encountered. Moreover, we recognize that the strategies outlined in this document are limited, and we encourage you to use your creativity to find new and unique ways to spread the Checklist. We have included in Appendix E a case study template that you can use to describe your experiences. Please submit these to us either by email ([email protected]) or by posting them to the IHI Open School Blog (http://www.ihiopenschool.blogspot.com).7 Finally, don’t forget that you will be most successful if you channel your energy into utilizing your social networks. They are very powerful and are our greatest asset at this point in our career!

7 For permission to post to the blog, contact Eva Luo: [email protected]



Authors and Contributors

The “Check a Box. Safe a Life.” Team Jordan Bohnen, Harvard University, United States; Andrew Carson-Stevens, School of Medicine, Cardiff University, United Kingdom; Lily Gutnik, Medical School for International Health, Israel; Shabnam Hafiz, UC Davis, Harvard University, United States; Dan Henderson, University of Connecticut, United States; and Eva Luo, University of Michigan, United States

Institute for Healthcare Improvement (IHI): Dr. Donald Berwick, Jill Duncan, Andy Jacaruso, Madge Kaplan, Joe McCannon, Shannon Mills, and Deepa Ranganathan Harvard Medical School and Harvard School of Public Health: Dr. Atul Gawande, Dr. William Berry, Bridget Craig, Priya Desai, Lizabeth Edmondson, John Rose, Laura Schoenherr, and Thomas Tsai 1000 Lives Campaign and Cardiff University School of Medicine: Professor Jonathan Gray, Peggy Edwards, Hamish Laing, Daniel Stevens, 1000 Lives Campaign Team, and Wales Chapter for Healthcare Improvement steering group American Medical Students Association (AMSA): Ben Goold and Marina Zeltser



Appendix A: WHO Surgical Safety Checklist



Appendix B: WHO Surgical Safety Checklist Resources

These materials are designed for use in all hospital settings worldwide and can be found on www.safesurg.org and www.who.int/safesurgery □ WHO Surgical Safety Checklist

This tool is the central component of the Safe Surgery Saves Lives program. The Checklist should be distributed to all clinicians and administrators that will be involved in the project (surgeons, nurses, technicians, anaesthetists, and hospital/clinical leaders).

□ Customizable WHO Surgical Safety Checklist Template Clinicians can use this document to modify the Checklist to better suit their needs while maintaining overall formatting. The template allows for the addition, elimination, reordering, and rewording of all line items on the Checklist.

□ Implementation Manual: WHO Surgical Safety Checklist 2009 This implementation manual is designed to help the members of the surgical team (surgeons, anaesthetists, nurses, technicians, and other operating room personnel) understand their roles in the use of the Checklist. It explains in detail how each line item on the Checklist should be performed in real life.

□ WHO Checklist Demonstration Videos The How-To and How-Not-To videos should be viewed by all operating theatre personnel. These videos bring the Checklist to life by clearly demonstrating the right and wrong ways it can be used.

□ New England Journal of Medicine Article, “A Surgical Safety Checklist to Reduce Morbidity and Mortality in a Global Population” Full text of the January 2009 New England Journal of Medicine article is available free of charge. This paper presents the results of a yearlong, global pilot study where the use of the Checklist was shown to reduce the rate of deaths and complications by more than one third in eight pilot hospitals. The rate of major inpatient complications dropped from 11% to 7%, and the inpatient death rate following major operations fell from 1.5% to 0.8% after implementation of the Checklist.

□ Frequently Asked Questions

This document provides answers to some frequently asked questions about the Checklist and Checklist implementation. It is divided into two sections, one for general questions about the Checklist or the Safe Surgery Saves Lives program and one for questions about Checklist implementation.



□ Speaker’s Kit/Introductory PowerPoint This PowerPoint presentation is designed to assist individuals when they are presenting the WHO Checklist and the Safe Surgery Saves Lives program to their colleagues.

□ Starter Kit This document provides a detailed explanation of strategies for putting the Checklist into place in a hospital, a means of identifying essential staff members and clinicians who must be involved, and a guide for troubleshooting a few commonly experienced problems.

□ WHO Surgical Safety Checklist Adaptation/Modification Guide Most hospitals will want to tailor the Checklist to the needs and processes of care in their specific environments and surgical disciplines. This document outlines the considerations one must keep in mind while modifying the Checklist in order to ensure that modifications do not compromise the ultimate utility of the tool.

□ Modified Checklists A number of modified Checklists from hospitals across the world serve as examples for those in the process of creating their own modifications.

□ Does My Checklist Meet the Goals of the WHO’s Checklist?

This document offers three questions an institution can use to measure the success of their modified Checklist. When coupled with the Checklist Adaptation/Modification Guide, this document helps to ensure that your Checklist meets the spirit of the WHO Surgical Safety Checklist.

□ WHO Guidelines for Safe Surgery

Although not recommended for wide distribution, this document is an exhaustive companion to the Checklist. The Guidelines contain the clinical evidence behind each of the 19 Checklist items and has been organized into three sections: specific objectives for safe surgical care, findings from reviews of evidence on and experience with approaches to meeting each of the objectives, and potentially beneficial practices.

□ Safe Surgery Saves Lives Brochure

The brochure serves as an introduction to the Safe Surgery Saves Lives program and the WHO Surgical Safety Checklist.

□ Web-based Tracking Map

This map shows which facilities have indicated either their intent to use the Checklist or have reported that they have started using the Checklist. To put your hospital on the map please register here: http://www.who.int/patientsafety/safesurgery/hospital_form/en/index.html.

□ The Safe Surgery Saves Lives Team

We are always available to answer questions, troubleshoot problems, or brainstorm ideas. Please contact us via email: [email protected] or [email protected]



Appendix B (continued): WHO Surgical Safety Checklist Resources These materials are modified for use in U.S. hospitals and other developed world settings and can be found on the Institute for Healthcare Improvement website: http://www.ihi.org/IHI/Programs/ImprovementMap/WHOSurgicalSafetyChecklist.htm □ Customizable Modified Checklist Template – U.S. Hospitals

This version of the Checklist template has already been modified to better suit the needs of U.S. and other developed world hospitals by including components of The Joint Commission Universal Protocol and Surgical Care Improvement Project (SCIP) measures.

□ Customizable IHI Modified Checklist Template with Introduction – U.S. Hospitals This document has the U.S. modifiable Checklist template as well as a basic introduction explaining what modifications were made.

□ Starter Kit (U.S. Hospitals) This document provides a detailed explanation of strategies for putting the Checklist into place in a hospital. This document has been modified to better suit the needs of a hospital in the U.S. or other developed world sites.

□ WHO Checklist Frequently Asked Questions (Modified for U.S. Hospitals) This document provides answers to some frequently asked questions and specifically addresses specific issues for U.S. hospitals, including how to integrate the Checklist with The Joint Commission Universal Protocol requirements.



Appendix C: Letter to Mentor/Advisor

Date Name Address City, State, Zip/Postal Code Country Dear Prof./Dr. _____________,

In January of 2009 a multi-site pilot study was published in The New England Journal of Medicine which found that a simple 19-item checklist was able to reduce morbidity and mortality by more than 30 percent. This checklist, the World Health Organization (WHO) Surgical Safety Checklist, was created and tested by a team of international experts, including anaesthetists, operating theatre nurses, surgeons, patients, and other professionals. The Checklist was studied in a multi-center pilot study where facilities ranged from a small district hospital in rural Tanzania to a large academic medical center in the United States. As of January 2010, more than 3,500 hospitals representing 120 countries had registered as participating hospitals, indicating that they started to use the Checklist or that they are in the process of introducing it in their operating theatres. Government bodies throughout the world have also committed to this program, with more than 21 countries mobilizing resources to implement the WHO Surgical Safety Checklist on a national scale.

I/we would like to further discuss the WHO Surgical Safety Checklist with you and learn more about the patient safety initiatives that are currently in use in your operating theatres. Furthermore, we would like to discuss ways in which students can work with you to improve surgical safety at ______ (insert hospital/university name here). Thank you for your time and consideration. I look forward to hearing from you. Please feel free to contact me at _________ (e-mail address) or _______ (phone number). Sincerely, _________ (signature)



Appendix D: Data Collection Sheet

Before Induction of Anaesthesia

Perceived to be part of current process (Y/N)?

% of time actually completed based on data (or write unable to collect)

Verbal confirmation with patient of identity, procedure, and consent

Site marked by patient’s surgeon

Anaesthesia safety check of machine and medications

Pulse oximeter used in all cases

Airway evaluated and score documented

Before Skin Incision Part of current process (Y/N)?

% of time completed (or write unknown)

Introduction by name and role Verbal confirmation of patient, site and procedure immediately before incision with all team members present (often called a time out)

Explicit discussion of specifics of case with all team members present including operative duration, patient comorbidities, and other critical issues

Use of sterility indicators Before Patient (and Surgeon) Leave Operating Room

Part of current process (Y/N)?

% of time completed (or write unknown)

Formal post-operative debriefing



Appendix E: Case Study Template ID (Name, Title, Institution, Contact Information) Dates Start: End: (Completed case study) Purpose Background Methods Results Quantitative Qualitative Conclusions/Discussion Success Factors Barriers to Success Recommendations

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