Checklists may have some value to protect patients who undergo surgery, but the potential benefits don't translate into "meaningful improvements" in outcomes, a new study of Ontario hospitals has concluded.

A group of researchers, including three Toronto surgeons, wanted to find out whether surgical safety checklists were saving lives or resulting in other benefits for patients at 101 hospitals in the province.

They looked at such things as post-operative complications, rates of hospital readmission, and operative mortality — analyzing the outcomes of surgical procedures performed before and after the adoption of surgical safety checklists.


Dr. Chris Hayes of the Canadian Patient Safety Institute says when used correctly, checklists do work.

The group decided to look at a three-month period before a checklist policy was implemented and compare it with a three-month period after checklists were adopted.

Their findings were to be published in Thursday's issue of the New England Journal of Medicine (NEJM).

"In conclusion, our study of the implementation of surgical safety checklists in Ontario did not show the striking improvement in patient outcomes identified in previous studies," the researchers said.

Checklists based on WHO model

The hospitals were asked what they were using: a 19-item checklist from World Health Organization issued in 2008, a similar but longer 26-item list from the Canadian Patient Safety Institute released the following year; or a unique checklist written up by an individual hospital.


One of the researchers says in most studies showing checklists to be effective, the hospitals have coupled them with other safety initiatives that go beyond the operating room. (Universal Images Group/Getty Images)

Hospitals in several countries, including the U.S., Canada, the Netherlands, and the U.K. have introduced the checklists. The checklists are mandated in hospitals across Canada.

Back in 2009, a study published in the NEJM found that using a checklist substantially reduced the rate of surgical complications, from 11 per cent to seven per cent, and reduced the rate of in-hospital death from 1.5 per cent to 0.8 per cent.

But in the Ontario study, the adjusted risk of death in the hospital or within 30 days after discharge was 0.71 per cent before the introduction of a checklist. That number dipped slightly to 0.65 per cent after a checklist was brought in.

Operative mortality was defined as the rate of death occurring in the hospital or within 30 days after surgery.

There was a small decrease in the adjusted length of a hospital stay, from 5.11 days before the checklist to 5.07 days after. The adjusted risk of surgical complications within 30 days after the procedure was 3.86 per cent before implementation of a checklist and 3.82 per cent after.

Better communication

"The way the checklist in theory helps is by improving communication among all the people on the surgical team," said study author Dr. David Urbach.

"It helps by making sure that important points that need to be covered during an operation aren't forgotten, for example, giving a patient antibiotics when they're supposed to have antibiotics administered," he said.

Dr. Lucian Leape, a U.S. policy adviser on patient safety and professor at the Harvard School of Public Health, wrote an editorial on the study for the NEJM and said it outlines the limitations of using checklists.

He said many hospitals lack the resources and expertise to fully implement a checklist and collect the information

"It is not the act of ticking off a checklist that reduces complications, but performance of the actions it calls for," Leape said.

"The checklist only works when you use it," he added

He also noted that 90 per cent of the Ontario hospitals in the study were using the WHO or the Canadian Patient Safety Institute checklist. Leape suggested they would be better served if they had their own modified lists.