Ready? Check! Igor Emmerich/Plainpicture

Scalpel, forceps, pen and paper. A paper checklist is a life-saving part of a surgeon’s toolkit, but some choose not to use it.

The 19-point safety checklist helps surgeons and anaesthetists avoid making preventable errors, like taking out the wrong kidney, or operating on the wrong patient.

But some doctors think they couldn’t make such basic errors, and won’t use it. So now one anaesthetist has come up with a way to make them: empower nurses to refuse to allow patients to leave the operating theatre until the form is complete.


“It penalises the whole team,” says Rajkumar Rajendram of King’s College London, who developed the approach while he was at the Royal Free Hospital in London. During his time there, audits revealed that checklist completion rates could be as low as 50 per cent.

Wrong operation

Sometimes things go wrong in healthcare that can’t be prevented, such as a delayed diagnosis due to someone having atypical symptoms. But other times errors may be down to negligence; one UK study estimated that 1 in 20 deaths in hospitals were probably due to medical errors.

Since 2009, NHS hospitals in the UK have been required to use the World Health Organization Safe Surgery checklist, which is designed to stop avoidable errors during operations. The most serious are called never events, because they shouldn’t ever happen.

The checklist asks surgical teams to do things like confirm a patient’s name, make sure the correct body part has been marked and check they have the right type of spare blood available if something goes wrong. Several studies have shown that doing this reduces deaths and complications of surgery by about one third.

But some surgeons think it’s beneath them, says Martin Bromiley of the UK patient safety body Clinical Human Factors Group. In the UK there were 255 never events during operations in the year 2012 to 2013. As well as operating on the wrong body parts, these included implanting the wrong medical device in a patient, or leaving a swab inside someone’s body – a mistake that can cause infection.

Empowering nurses

While Rajendram was a staff member at the Royal Free Hospital, two audits found that the checklist was completed in only 67 and 50 per cent of operations, prompting his team to experiment with ways to encourage their colleagues to fully fill out their checklists.

They found that allocating responsibilities for different sections of the checklist to different members of the surgical team pushed the completion rate up to 94 per cent. However, they thought this figure was likely to drift down again without continual monitoring.

So they got tough, by changing procedures so the nurse in charge of the recovery room would not give patients a bed without a completed form. That prevents the theatre team doing any further operations until their patient has left, says Rajendram. This sent the rate up to 100 per cent, where it has stayed in several further audits.

However, even that may not be enough to keep all doctors in line. Bromiley has heard of some surgeons cheating by signing batches of forms in advance. He wants hospitals to do regular checks observing how surgeons use the form in practice. “I struggle to think of any other professional groups where this kind of behaviour would be tolerated,” he says.

Read more about mind slips that can cause catastrophe, and how to avoid them.