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By Root 839 0

get of the University of Washington Medical Center—over one billion dollars per year—was more than twice that of the entire country of Tanzania. Surgery therefore differed starkly in our eight hospitals. On one end of the spectrum were those with state-of-the-art capabilities allowing them to do everything from robotic prostatectomies to liver transplants, along with factory loads of planned, low-risk, often day-surgery procedures like hernia repairs, breast biopsies, and ear-tube placements for drainage of chronic ear infections in children. On the other end were hospitals forced by lack of staff and resources to prioritize urgent operations—emergency cesarean sections for mothers dying in childbirth, for example, or procedures for repair of severe traumatic injuries. Even when the hospitals did the same operations—an appendectomy, a mastectomy, the placement of a rod in a broken femur—the conditions were so disparate that the procedures were the same only in name. In the poorer hospitals, the equipment was meager, the teams’ training was more limited, and the patients usually arrived sicker—the appendix having ruptured, the breast cancer having grown twice as large, the femur proving not only broken but infected.

Nonetheless, we went ahead with our eight institutions. The goal, after all, was not to compare one hospital with another but to determine where, if anywhere, the checklist could improve care. We hired local research coordinators for the hospitals and trained them to collect accurate information on deaths and complications. We were conservative about what counted. The complications had to be significant—a pneumonia, a heart attack, bleeding requiring a return to the operating room or more than four units of blood, a documented wound infection, or the like. And the occurrence had to actually be witnessed in the hospital, not reported from elsewhere.

We collected data on the surgical care in up to four operating rooms at each facility for about three months before the checklist went into effect. It was a kind of biopsy of the care received by patients across the range of hospitals in the world. And the results were sobering.

Of the close to four thousand adult surgical patients we followed, more than four hundred developed major complications resulting from surgery. Fifty-six of them died. About half the complications involved infections. Another quarter involved technical failures that required a return trip to the operating room to stop bleeding or repair a problem. The overall complication rates ranged from 6 percent to 21 percent. It’s important to note that the operating rooms we were studying tended to handle the hospital’s more complex procedures. More straightforward operations have lower injury rates. Nonetheless, the pattern confirmed what we’d understood: surgery is risky and dangerous wherever it is done.

We also found, as we suspected we would, signs of substantial opportunity for improvement everywhere. None of the hospitals, for example, had a routine approach to ensure that teams had identified, and prepared for, cases with high blood-loss risk, or conducted any kind of preoperative team briefing about patients. We tracked performance of six specific safety steps: the timely delivery of antibiotics, the use of a working pulse oximeter, the completion of a formal risk assessment for placing an airway tube, the verbal confirmation of the patient’s identity and procedure, the appropriate placement of intravenous lines for patients who develop severe bleeding, and finally a complete accounting of sponges at the end of the procedure. These are basics, the surgical equivalent of unlocking the elevator controls before airplane takeoff. Nevertheless, we found gaps everywhere. The very best missed at least one of these minimum steps 6 percent of the time—once in every sixteen patients. And on average, the hospitals missed one of them in a startling two-thirds of patients, whether in rich countries or poor. That is how flawed and inconsistent surgical care routinely is around the world.

Then, starting