Level 2: Mid-level evidence
A surgical safety checklist developed by the WHO to facilitate communication and safety checks was associated with reduced surgical mortality in a before-and-after study at eight hospitals. Now, a large cohort study with 182,409 surgical procedures conducted at Veterans Health Administration (VHA) facilities from 2006 to 2008 has assessed the efficacy of a team training program that incorporates a checklist (JAMA. 2010;304:1693-1700). This team training program is now mandated at all VHA facilities in which surgery is performed. The program emphasizes teamwork and communication among clinicians, with training in the use of a checklist to guide pre- and postoperative briefings; strategies for communicating safety risks and red flags; rules for conduct of communication; and effective communication during care transitions.
Surgical outcomes at 74 VHA facilities that implemented the training program during the study period were compared with outcomes from 34 facilities that had not started the training. Because implementation of the program was not randomized, facilities were propensity-matched for the probability of starting the program during the study period. Matching was based on a number of factors, including baseline mortality and morbidity rates as well as hospital size, location, and surgical load. There were no significant differences in mortality between the trained and untrained facilities at baseline. Facilities with training had a decrease in average surgical mortality rates from 17 to 14 per 1,000 procedures. At the end of the study, trained facilities had an 18% reduction in annual mortality compared with baseline (rate ratio 0.82, 95% CI 0.76-0.91), whereas mortality dropped at untrained facilities by 7% (not significant). In a propensity-matched analysis, training was associated with a significantly greater risk reduction in surgical mortality compared to no training (rate ratio 1.49, 95% CI 1.1-2.07).