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By Root 807 0

and hands of patients to keep them from inadvertently reaching around the sterile drapes and touching the surgeons or the operative field. In this instance, however, the regular routine would have caused a serious problem, but this was not clearly recognized by the team until just before the incision was made. That was when the surgeon walked in, pulled on his gown and gloves, and stepped up to the operating table. Because of the checklist, instead of taking the knife, he paused and conferred with everyone about the plans for the operation. The Toronto report included a transcript of the discussion.

“Are there any special anesthetic considerations?” the surgeon asked.

“Just his dysarthria,” the anesthesiologist said, referring to the patient’s inability to speak.

The surgeon thought for a moment. “It may be difficult to gauge his neurological function because we have these issues,” he said.

The anesthesiologist agreed. “I’ve worked out a system of hand signals with him.”

“His arm will [need to] be accessible then—not tucked,” the surgeon said. The anesthesiologist nodded, and the team then worked out a way to leave the patient’s arms free but protected from reaching around or beneath the drapes.

“My other concern is the number of people in the room,” the anesthesiologist went on, “because noise and movement may interfere with our ability to communicate with the patient.”

“We can request silence,” the surgeon said. Problem solved.

None of these studies was complete enough to prove that a surgical checklist could produce what WHO was ultimately looking for—a measurable, inexpensive, and substantial reduction in overall complications from surgery. But by the end of the Geneva conference, we had agreed that a safe surgery checklist was worth testing on a larger scale.

A working group took the different checklists that had been tried and condensed them into a single one. It had three “pause points,” as they are called in aviation—three points at which the team must stop to run through a set of checks before proceeding. There was a pause right before the patient is given anesthesia, one after the patient is anesthetized but before the incision is made, and one at the end of the operation, before the patient is wheeled out of the operating room. The working group members divvied up the myriad checks for allergies, antibiotics, anesthesia equipment, and so on among the different pause points. They added any other checks they could think of that might make a difference in care. And they incorporated the communication checks in which everyone in the operating room ensures that they know one another’s names and has a chance to weigh in on critical plans and concerns.

We made a decision to set up a proper pilot study of our safe surgery checklist in a range of hospitals around the world, for which WHO committed to providing the funds. I was thrilled and optimistic. When I returned home to Boston, I jumped to give the checklist a try myself. I printed it out and took it to the operating room. I told the nurses and anesthesiologists what I’d learned in Geneva.

“So how about we try this awesome checklist?” I said. It detailed steps for everything from equipment inspection to antibiotic administration to the discussions we should have. The rest of the team eyed me skeptically, but they went along. “Sure, what ever you say.” This was not the first time I’d cooked up some cockamamie idea.

I gave the checklist to Dee, the circulating nurse, and asked her to run through the first section with us at the right time. Fifteen minutes later, we were about to put the patient to sleep under general anesthesia, and I had to say, Wait, what about the checklist?

“I already did it,” Dee said. She showed me the sheet. All the boxes were checked off.

No, no, no, I said. It’s supposed to be a verbal checklist, a team checklist.

“Where does it say that?” she asked. I looked again. She was right. It didn’t say that anywhere.

Just try it verbally anyway, I said.

Dee shrugged and started going through the list. But some of the checks were