The origins of the checklist!

On October 30, 1935, at Wright Air Field in Ohio, the U.S. Army organized a competition for aircraft manufacturers wishing to build the next generation of long-range bombers. Several members (high-ranking officers) of the army and executives from the aeronautical industry were present.

Shimmering, the Boeing 299 model enters the scene. Made of aluminum alloy, the B299 can carry five times more bombs than the army requested; it can fly faster than previous bombers and almost twice as far.

During the initial evaluations, a journalist nicknamed it the "Flying Fortress", and the name stuck.

The plane roars down the tarmac, takes off smoothly and soars to 300 feet, then stalls, turns on one wing and crashes in a fiery explosion. Two of the five crew members are dead, including the pilot, Major Hill.

The subsequent investigation reveals no mechanical problems. The accident is due to "pilot error."

In practice, the new airplane requires the pilot to manage four engines, a retractable landing gear, new wing flaps, electric trim tabs that must be adjusted to maintain control at different speeds, and constant speed propellers... among other things.

In doing all this, the pilot forgot to release a new locking mechanism on the elevator and rudder controls. The Boeing model was deemed "too complex for one man to fly," and the army declared another model the winner, ordering only a few planes for testing. Boeing nearly went bankrupt. It's difficult to demand more advanced training for pilots because Major Hill was one of the most expert and experienced pilots in the U.S. Army.

Instead, an ingeniously simple approach was proposed: a checklist with step-by-step verifications (ignition, takeoff, flight, landing, and taxiing). Its mere existence shows how far aeronautics has progressed. In the early years of aviation, getting a plane off the ground could be nerve-wracking, but it was hardly complex. The use of a takeoff checklist would no more have crossed a pilot's mind than it would a driver pulling their car out of the garage. But this new plane was too complicated to be left to the memory of a pilot, however expert.

One conclusion to be drawn from this story: expertise and experience do not protect against accidents!

Does that ring a bell? What an echo almost 100 years later with today's medicine!

In 2022, patient safety has become a major health issue for which the entire SafeTeam Academy team is working through the development of innovative training programs. Indeed, many tools exist but are not always known to caregivers, nor even used.

A case in point? The surgical checklist, known to French healthcare professionals as the HAS checklist. It has historically been promoted by the WHO and a team led by Atul GAWANDE, whom our founders, Dr MARTIN and JAULIN, were lucky enough to meet in 2017 in Boston.

Atul GAWANDE is one of the main authors of the seminal article published in the New England Journal of Medicine that we encourage you to read.

The surgical checklist is a tool that structures teamwork and provides a situation update in the form of briefings and debriefings. The checklist provides a shared mental framework with clear objectives at each stage of the patient's care pathway.

It takes place in 3 phases:

• Phase 1: Before anesthetic induction, the time-out prior to anesthesia.

This involves checking several points, including the patient's identity, the nature of the intervention and the surgical site, the patient's positioning, skin preparation, equipment and materials, as well as allergic, respiratory, and hemorrhagic risks.

• Phase 2: Before the surgical intervention, the time-out prior to incision.

This phase allows for a final verification regarding the intervention, but also to carry out an oral sharing of essential information concerning any critical points.

• Phase 3: After the surgical intervention, the time-out before leaving the operating room.

The last step, before the patient and the staff leave the operating room, is to ensure that the objectives have been achieved and that the postoperative prescriptions are compliant.

When routinely implemented, the surgical checklist takes an average of 3 minutes to complete. Failure to do so exposes patients to risks that can delay care by several hours or even seriously endanger the patient.

Why optimize its implementation?

This surgical checklist is not always used, and when it is used, it is not always performed optimally, particularly in the sharing of information within the team. However, when properly executed, the surgical checklist reduces serious perioperative complications by approximately 50%.

It also encourages all stakeholders to discuss the intervention that will take place by doing a briefing and a debriefing, thereby promoting teamwork and communication.

‍How tooptimize its completion? Our tips for improving the surgical checklist

Firstly, it is about raising awareness among field staff about teamwork and communication. This is the primary objective of our flagship training program, the one that has made SafeTeam Academy successful.

This training is also the first training ever designed on the checklist and was presented in 2019 at the Patient Safety Movement Foundation by the founders of SafeTeam Academy, after the speech by President Bill Clinton, who in particular instigated the publication of the famous report To Err is Human.

It reviews the main principles of good implementation, and also addresses other essential topics such as task interruptions, feedback and other areas of HAS V2020 certification.

We also advise you to adapt the checklist because surgical activities differ greatly in their risk management. What are the risks in orthopedic surgery of the upper limb, in cardiac surgery, in pediatrics...?

Feedback shared on the Patient Safety Database, in a cardiac surgery situation, illustrates the need to adapt the checklist. You can consult it in this patient safety report: http: //www.patientsafetydatabase.com/pdf/fr/2021-01-PSR18-fr.pdf‍

Adaptation also allows for better adoption by the team.

Adaptation of the checklist may be suggested by the analysis of accidents or near-misses (situation recovered before it caused damage).

Encourage your healthcare providers to share their experience, which is very valuable for the organization because it allows for discussion of the robustness of safety barriers. If these barriers have all failed or luck has played a role, then the activity model needs to be reviewed as a team.

Moreover, in the 3rd step of the checklist, which we advise seeing as a debriefing, participants are encouraged to consider whether there is an event to share with their organization. Feedback is therefore also part of the checklist.

‍SafeTeamAcademy and the checklist

Through its innovative training programs, SafeTeam Academy aims to support and provide caregivers with the tools necessary for the proper use of the surgical checklist. Advice, warnings, practices to adopt... by expert and professional caregivers from other high-risk industries!

If you too would like to play your part in improving the reliability of care within your facilities, opt for SafeTeam Academy training courses and contact us to find out more.