Dr. Gawande Touts Crisis Checklists

Checklists used during rare surgical emergencies help to avert disaster, according to Atul Gawande, MD, MPH, a surgeon at Brigham and Women's Hospital in Boston and renowned author of The Checklist Manifesto.

In a study published in the New England Journal of Medicine, Dr. Gawande and colleagues report that 17 OR teams that used checklists during 106 simulations of surgical crises such as cardiac arrest, air embolism, anaphylaxis, and hemorrhage were 75% more likely to perform 47 key life-saving steps in care than those who managed the staged emergencies from memory alone. Nearly all of the caregivers in the study said they would want emergency checklists used during cases in which they were patients.

Even though the use of checklists have been proven to improve surgical safety, Dr. Gawande sees frontline compliance falling short due to surgeons and surgical teams who balk at the added time needed to incorporate the tool into established perioperative routines.

He believes checklists are essential patient safety tools, even if the core values they promote — humility, teamwork and discipline — often run counter to the surgeon-led team model ingrained in most ORs.

"Four years ago, we showed that completing a routine checklist before surgery can substantially reduce the likelihood of a major complication," he says. "This new work shows that use of a set of carefully crafted checklists during an operating room crisis also has the potential to markedly improve care and safety."

Daniel Cook

OR Ergonomics: Planned Breaks Are Good, But Unplanned Ones Result in Errors

Planned "micropauses" are effective at preventing muscle fatigue over long surgical procedures, according to an article in the February Annals of Surgery, while unplanned interruptions result in higher error rates, say researchers at Michigan State University.

In one study, 16 surgeons were tested in 3 situations: before any surgery, and twice after a procedure at least 2 hours long — once with formal "micropauses," and once without. Micropauses are 20-second breaks every 20 minutes. Researchers tested muscular fatigue by having the surgeons hold a 2.5-kg weight as long as possible in an extended arm, then by measuring mistakes when the surgeons followed "a predetermined path on a board." Discomfort was also measured with a visual analog scale. The results: Micropauses completely or almost completely ameliorated the significant muscular fatigue associated with surgery.

In the other study, 300 people performed a sequence-based procedure on a computer — such as identifying with a keystroke whether a letter was closer to the start or the end of the alphabet. Even without interruptions a small number of errors in sequence were made. Sometimes participants were interrupted and told to type two letters — which took 2.8 seconds, essentially the time it takes to silence a buzzing smartphone — before returning to the task. When this happened, they were twice as likely to incorrectly enter the sequence.

"What this means is that our health and safety is, on some level, contingent on whether the people looking after it have been interrupted," says Erik Altmann, lead researcher on the study and an associate professor of psychology at MSU.

Stephanie Wasek

Metal-on-Metal Hip Implants Under Scrutiny

The U.S. Food and Drug Administration has proposed regulations that would halt the sale of metal-on-metal hip implants, and the approval of new models, until manufacturers prove their safety and effectiveness.

The all-metal implants were designed on the concept that they would be more durable than prosthetic hips incorporating ceramic or metal balls and plastic sockets. But they've shown a high rate of failure before reaching their projected 15-year lifespan, and subjected patients to bone and tissue damage, metal particles in joints and additional replacement surgeries.

The FDA's move seeks to close a decades-old loophole. While metal-on-metal hips were once frequently implanted — about half a million Americans have received them — they were never subjected to rigorous clinical testing as a result of medical device legislation that was enacted as a temporary solution but never revisited.

In May 2011, the FDA ordered 20 implant manufacturers to conduct studies of their all-metal hips to determine their failure rates and the impact that failures would have on patients.

David Bernard

InstaPoll: Is Robotic Surgery All Hype?

Does robotic surgery offer any advantage over traditional laparoscopic surgery, or is it more marketing hype than clinical benefit? Tell us what you think in this week's InstaPoll.

Of all the distractions you face in your job, office drop-ins are the No. 1 time bandit, according to the 409 facility managers who took last week's poll. The results:

  • Office drop-ins (staff, surgeons, vendors): 37%
  • E-mail: 26%
  • Meetings: 23%
  • Phone calls: 14%
  • Facebook: 0%

Dan O'Connor

News & Notes
  • Cataract surgery effective at 10 years Cataract extraction with IOL implantation is effective, offering "good long-term visual rehabilitation for the majority of patients," according to an article in Acta Ophthalmologica. Approximately half of the 335 patients assessed 10 years post-op had no deterioration in subjective visual function, and 77% had a decline of 10 points or fewer. Twelve percent experienced a worsening of more than 30 points. The most common cause for large functional loss after 10 years was age-related macular degeneration.
  • The weight of malpractice claims The average physician who finds himself a defendant in a malpractice lawsuit can expect to spend nearly 11% of his career waiting for its resolution, according to an analysis by healthcare policy experts at Harvard Medical School and the Rand Corporation. Their report, published in the January issue of the journal Health Affairs, calculate that claims are typically filed nearly 2 years and resolved over 43 months after incidents. They speculate that the resulting emotional weight on physicians and their patients is as great as the financial toll.
  • HD camera in development Researchers at the University of Arizona are perfecting a high-definition endoscopic camera that lets physicians simultaneously see wide angle and close-up images without having to move the lens. The researchers say their innovation will maintain a surgeon's peripheral vision within the surgical cavity. Because the camera can remain stationary the advance may also prevent clashing with other instruments, facilitate operating through fewer ports and eliminate the need for surgical assistants to guide cameras.