201765 ChecklistsinNeurosurgerytoDecreasePreventableMedicalErrors:AReview

BalkanMedJ.2015Oct32(4):337346. PMCID:PMC4692331
Publishedonline2015Oct1.doi:10.5152/balkanmedj.2015.15481

ChecklistsinNeurosurgerytoDecreasePreventableMedicalErrors:
AReview
YavorEnchev
DepartmentofNeurosurgery,MedicalUniversityofVarna,St.MarinaUniversityHospital,Varna,Bulgaria
AddressforCorrespondence:Dr.YavorEnchev,DepartmentofNeurosurgery,MedicalUniversityofVarna,St.MarinaUniversityHospital,
Varna,Bulgaria,Phone:00359888441191email:dr.y.enchev@gmail.com

Received2015Mar30Accepted2015Apr4.

Copyright2015TrakyaUniversityFacultyofMedicine

Abstract Goto:

Neurosurgeryrepresentsazerotoleranceenvironmentformedicalerrors,especiallypreventableoneslike
alltypesofwrongsitesurgery,complicationsduetotheincorrectpositioningofpatientsforneurosurgical
interventionsandcomplicationsduetofailureofthedevicesrequiredforthespecificprocedure.

Followingtheexcellentandencouragingresultsofthesafetychecklistsinintensivecaremedicineandin
othersurgicalareas,thechecklistwasnaturallyintroducedinneurosurgery.Todate,thereportedworld
experiencewithneurosurgicalchecklistsislimitedto15serieswithfewerthan20,000casesinvarious
neurosurgicalareas.

Thepurposeofthisreviewwastostudythereportedneurosurgicalchecklistsaccordingtothefollowing
parameters:yearofpublicationcountryoforiginareaofneurosurgerytypeofneurosurgicalprocedure
electiveoremergencypersoninchargeofthechecklistcompletionparticipantsinvolvedincompletion
whethertheypreventedincorrectsitesurgerywhethertheypreventedcomplicationsduetoincorrect
positioningofthepatientsforneurosurgicalinterventionswhethertheypreventedcomplicationsdueto
failureofthedevicesrequiredforthespecificproceduretheirspecificaimseducationalpreparationand
trainingthetimeneededforchecklistcompletionstudydurationandphasesnumberofcasesincluded
barrierstoimplementationeffortstoimplementationteamappreciationandsafetyoutcomes.

Basedonthisanalysis,itcouldbeconcludedthatneurosurgicalchecklistsrepresentanefficient,reliable,
costeffectiveandtimesavingtoolforincreasingpatientsafetyandelevatingtheneurosurgeonsself
confidence.Everyneurosurgicaldepartmentmustdevelopitsownneurosurgicalchecklistoradoptand
modifyanexistingoneaccordingtoitsspecificfeaturesandneedsinanattempttoestablishordevelop
itssafetyculture.Theworld,continental,regionalandnationalneurosurgicalsocietiescouldpromote
safetychecklistsandtheirbenefits.

Keywords:Checklist,neurosurgery,patientsafety,medicalerrors

Neurosurgery,althoughbeingoneofthemosthightechsurgicalareas,isnotreliablyprotectedagainst
preventablemedicalerrorslikeallsubtypesofincorrectsurgerysite,complicationsduetoincorrect
positioningofthepatientsforneurosurgicalinterventionsandcomplicationsduetofailureofthedevices
requiredforthespecificprocedure.Inanattempttoincreasepatientsafetyandreducetheriskfactors,
checklistswereintroducedandimplementedinthiszerotoleranceenvironment.Neurosurgicalchecklists
representbothsourceandpracticalexpressionofasafetycultureinneurosurgery.

Theprimaryobjectiveofthisreviewwastohighlightthecurrentstateofthechecklistapplicationin
neurosurgeryaswellastooutlineitsfuturetrendsconcerningareductionofpreventablemedicalerrors.

PREVENTABLEMEDICALERRORSINNEUROSURGERY Goto:
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201765 ChecklistsinNeurosurgerytoDecreasePreventableMedicalErrors:AReview

Medicalerrorscanbedefinedasavoidableadverseeffectsofmedicalcare,regardlessofwhetherornot
theyareobviousordamagingforthepatient(1).

Thepreventablemedicalerrorsinneurosurgery,whicharetheobjectiveofthisreview,includeall
subtypesofincorrectsurgerysite,complicationsduetoincorrectpositioningofthepatientsfor
neurosurgicalinterventionsandcomplicationsduetoafailureofthedevicesrequiredforthespecific
procedure.

Incorrectsitesurgery
Thetermwrongsitesurgeryisoftenusedasageneraldesignationofseveralsubtypesofincorrectsite
surgicalevents:incorrectsitesurgery(inparticular)surgicalprocedureaccomplishedonanincorrect
bodypartwronglevelsurgerysurgicalprocedureperformedatanerroneouslevelbutatthecorrectsite
wronglevelexposuresurgicalexposurecompletedonamistakenlevelwrongsidesurgerysurgical
procedureperformedonthewrongsideofthebodyoronthewrongextremityincorrectprocedurethe
wrongsurgicalprocedureperformedontherightsideandsiteandincorrectpatientintervention
performedonthewrongpatient(2).

Complicationsduetoincorrectpositioningofthepatientsforneurosurgicalprocedures
Positioningofneurosurgicalpatientsisanimportantpartofeveryprocedureandpayingattentiontothe
physicalandphysiologicalconsequencesofincorrectpositioningcanpreventseriousadverseeventsand
complications.Idealpatientpositioninginvolvesbalancingsurgicalcomfortagainsttherisksrelatedtothe
patientposition.

Complicationsduetoincorrectpositioningofthepatientsforneurosurgicalproceduresinclude
perioperativenerveinjuryandpostoperativevisualloss(3).Theperioperativenerveinjurycouldbe
brachialplexusinjury,ulnarneuropathy,medianneuropathyandradialneuropathy.Themostcommon
causesofpostoperativevisuallossareischemicopticneuropathyandcentralretinalarteryocclusion(3).

Complicationsduetofailureofthedevicesrequiredfortheprocedure
Mostoftheneurosurgicalproceduresrequiredevicesfortheircompletion,likehighspeeddrills,
operatingmicroscopes,neuroendoscopes,ultrasounds,Carms,neuronavigation,cavitronultrasonic
surgicalaspirators,etc.Inthecaseofmalfunctionofsuchdevices,dependingonthestageofthe
intervention,thesurgerymaynotbeperformedatall,orcouldfailtobecompletedinthepreoperatively
plannedmannerandextent.

RISKFACTORSFORPREVENTABLEMEDICALERRORSIN Goto:
NEUROSURGERY
Neurosurgeryrepresentsthethirdmostamenablesurgicalareatowrongsitesurgerynexttoorthopedics
andgeneralsurgery(4).

Riskfactorstowrongsitesurgeryincludeincorrectpatientpositioningorpreparationoftheoperativesite,
erroneousinformationprovidedbythepatientortheirfamily,missingorimproperpatientconsent,failure
tousesitemarkings,neurosurgeonexhaustion,severalneurosurgeonsinvolvedinonecase,multiple
proceduresonthesamepatient,unusualtimelimits,emergentprocedures,unusualpatientanatomy,and
overallpooroperativeteamcommunication(2).

Positioningofneurosurgicalpatientsischallenginginitscomplexityandvariability.Itistheresponsibility
ofboththeneurosurgeonandtheanesthesiologist.Ontheonehand,itrequiresanadequateanesthetic
depth,maintenanceofhemodynamicstability,evidenceofappropriateoxygenation,andthepreservation
ofinvasivemonitors.Ontheotherhand,thereisanecessityofoptimalphysiologicalpositionofthehead,
eyes,neck,extremities,breastsandgenitals,withoutanyabnormalcompression,traction,flexionor
extension(3).

Mostoftheneurosurgicaloperationscouldnotbeaccomplishedwithoutexcellenttechnicalsupportby
heterogeneousspecializedhightechequipment.Theperfectconditionoftheseindispensabledevices
requiredforeveryneurosurgicalprocedureisobligatoryforitsuneventfulcourse.
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Inanattempttocopewiththeaforementionedriskfactorsforpreventablemedicalerrorsinneurosurgery,
safetychecklistswereintroduced.

CHECKLISTDEFINITION Goto:

Thechecklist,bydefinition,representsatoolforcollectinginformationaimingtopreventthefailureof
somehumanactivityduetotheinherentlimitationsofhumanattentionandmemory.Itguaranteesthe
sequenceandaccomplishmentoftheplannedassignment(5).

NEUROSURGICALCHECKLISTS Goto:

TheneurosurgicalchecklistsreportedintheliteraturetodatearesummarizedandjuxtaposedinTable1
and2.

TABLE1.
Reviewoftheneurosurgicalchecklistsreportedintheliterature
regardingparameterssuchas:yearofpublicationcountryoforigin
areaofneurosurgerytypeofneurosurgicalprocedureelectiveor
emergencypersoninchargeofchecklistcompletion...

TABLE2.
Reviewoftheneurosurgicalchecklistsreportedintheliterature
regardingparameterssuchas:studydurationandphasesnumberof
casesincludedbarrierstoimplementationeffortsto
implementationteamappreciationandsafetyoutcomes

NEUROSURGICALCHECKLISTS Goto:

Distributionbyyear
Allbutoneofthestudiesreportingneurosurgicalchecklistswerepublishedwithinthelast6years.The
firstsafetysurgicalchecklistconcerningneurosurgerywasthatofNorthAmericanSpineSocietyand
waspublishedin2001(6).Itaimedtopreventincorrectsite,incorrectlevelandwrongpatientsurgeryin
spinalandorthopediccases.Thesecondneurosurgicalchecklistwasinthefieldofstereotacticand
functionalneurosurgeryandwasreportedonlyeightyearslaterwhenConnollyetal.(7)publishedtheir
checklistdesignedespeciallyforelectivenewdeepbrainstimulation(DBS)implantationcases.The
largestnumberofpapersdescribingneurosurgicalchecklistsandtheirresultswasobservedin2012
(almosthalfofallreports7/15)(5,1116).

Countryoforigin
Overall,11outof15(69%)papersreportingneurosurgicalchecklistswerefromtheUSA(5
9,12,13,1518).ThreestudiesoriginatedfromEurope(Spain(11),Germany(14)andFinland(19)and1
wasfromAsia(Japan)(10).Thesedataclearlydemonstratethattheproblemofpatientsafetyin
neurosurgeryismorerealandimportantforcolleaguesfromtheUSA,mostprobablyduetothe
peculiaritiesoftheirhealthsystemandthetraditionallyhigherlevelofmedicolegalissuesthere.The
increasingpopularityandinfluenceofpatientorganizations,aswellastheeverreducingtolerancein
modernsocietytomedicalerrors,especiallypreventableones,willmostlikelystimulatethewider
distributionofneurosurgicalsafetychecklistsinEurope.

Areaofneurosurgery
Overall,7outof15neurosurgicalchecklistswerereasonablydesignedandappliedingeneral
neurosurgery(8,10,11,1315,19),3wereinvascularneurosurgery(9,17,18),2instereotacticand
functionalneurosurgery(7,12),another2wereinspinalneurosurgery(6,16)and1wasregardingthe
placementofexternalventriculardrainage(5).Twoofthegeneralneurosurgerychecklistswere
developedtoguideandpreventerrorsinanintraoperativemagneticresonanceimaging(MRI)suite
(10,15).Thesenumbersclearlyreflectedthecasedistributioninthecommonneurosurgicalpractice.
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Typeofneurosurgicalprocedures
Mostofthecheckliststudiesincludebothelectiveandemergencycases(8outof15)(6,8,10,1316,18).
Onechecklistwasappliedinelectiveandvoluntarilyinemergencyprocedures(19).Threeofthe
neurosurgicalchecklistswerelimitedonlytoelectivesurgeries(7,11,12)andthesamenumberof
checklistswereimplementedforemergencycases(5,9,17).

Personinchargeforthechecklistcompletion
Thischaracteristicoftheneurosurgicalchecklistswasquitevariable.Thereportedexperienceincluded
severalpossibilitiesforthepersoninchargetocompletethechecklist.Theseweredifferentpersons
(neurosurgeon,anesthesiologistandnurseortechnologist)foreachparticularsectionofthechecklist
(6/15)(11,1417,19),theattendingneurosurgeon(3/15)(6,8,13),theresidentperformingtheprocedure
(1/15)(5),aneurointerventionalfellow(1/15)(18),aclinicianinchargewhoisnotfromthesurgical
team(1/15)(12),andtheondutysafetynurse(1/15)(10).In2studies,thepersoninchargeofthesafety
checkswasnotreported(7,9).

Participantsinthechecklistcompletion
Inanattempttoenhanceteamworkflowandcommunication,mostoftheneurosurgicalchecklists
requiredtheparticipationoftheentireoperativeteam(10/15)(1019).However,someofthemneeded
onlytheattendingneurosurgeon(2/15)(6,8)ortheresidentperformingtheplacementofexternal
ventriculardrainage(1/15)(5).Twoauthorsdidnotspecifytheparticipantsintheirchecklists(2/15)
(7,9).

Preventingincorrectsitesurgery
Thepreventionofalltypesofwrongsitesurgerywasalmostubiquitouslyoneoftheprimarygoalsofthe
neurosurgicalchecklists(11/15)(68,1015,18,19).Threeofthechecklists(3/15)(9,16,17)didnot
includethisitembecauseoftheirhighlyspecificandnarrowareasandsitesofaction,inwhichincorrect
sitesurgerydidnotexistasanoption.Onereportdidnotclarifythiselement(1/15)(5).

Preventingcomplicationsduetoincorrectpositioningofthepatientsfora
neurosurgicalprocedure
Only2neurosurgicalchecklists(2/15)(10,15)aimedtopreventcomplicationsduetoincorrect
positioningofthepatientsforaneurosurgicalprocedure.Theywerespeciallydesignedfortheprevention
ofpotentialcomplicationsinanintraoperativeMRIsuite(10,15).Thesparsepresenceofthisproblemin
theavailableneurosurgicalchecklistsrepresentsanoteworthyomissionwhichmustbecorrectedintheir
modificationsorinthenewlydevisedsafetychecklists.

Preventingcomplicationsduetoafailureofdevicesrequiredfortheneurosurgical
procedure
Only5outof15neurosurgicalchecklists(5/15)(7,10,12,14,15)incorporateditemstargetingthe
preventionofcomplicationsduetoafailureofthedevicesrequiredforneurosurgicalprocedures.The
safetycheckofallnecessarysystemsandmachinesintheoperatingtheatre,beingclosesttotheprototype
checksinaviation,isundulyunderestimatedincommonsafetyefforts.Thispotentialproblemcouldlead
todevastatingconsequencesandmustreceivethedeservedattentionandexertionsinthesafetymeasures.

Specificaims
Thespecificaimsoftheavailableneurosurgicalchecklistsvariedaccordingtotheirareaofneurosurgical
application(Table1).Itcouldnotbeexpectedthatstereotacticchecklists(7,12)forexamplewould
resembleendovascularones(9,17,18).Naturally,theyreflectedthesafetyexperience,attitudesand
cultureoftheindividualsandinstitutionsresponsiblefortheirelaborationandimplementation.

Educationalpreparationandtrainingregardingchecklistimplementation

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Theimplementationofthesafetychecklistsasaruleisprecededbyeducationaleventsandpreparation.
However,only5studies(5/15)oftheneurosurgicalchecklistsreportededucationalefforts
(6,10,13,15,19).Thesemeasuresincludedachecklistpostedintheoperatingroominahighlyvisible
area,educationaltraining,lectures,videos,mocktestandmockemergencycodedrill,andreadingaloud
asurgicalsafetymanualandchecklistduringtheperiodofpreparationforintraoperativeMRI.

Timeneededforchecklistcompletion
Thetimeneededforchecklistcompletionwasdetailedinonly3series(3/15)ofneurosurgicalchecklists
(7,10,13).Itrangedbetween1and8minutes.Notreportingtheaveragetimethatthechecklist
applicationaddedtothetotaloperativetimecouldbeconsideredasignificantdrawbackofeachofthose
papers.Theregulartimespentfortheneurosurgicalchecklistsintheoperatingtheatreisveryimportantin
evaluatingtheircosteffectiveness.

Studydurationandphases
Tenoftheseries(10/15)withneurosurgicalchecklistspresentedtheirstudydurationandphases.The
mostlongtermstudywasthatofLyonsetal.(8)whichcoveredaperiodof8yearsandwasnotdivided
inphases.TheseriesofOszvaldetal.(14)continued5yearsandincludedtwophases(Phase1,
perioperativechecklist,4yearsandPhase2,advancedperioperativechecklist,1year).McConnelletal.
(5)andMcLaughlinetal.(13)had4yearsofexperienceandnostudyphases.Matsumaeetal.(10)and
Rahmathullaetal.(15)reported3yearsand2yearsand4months,respectively,fortheirstudyduration
andnostudyphases.DaSilvaFreitasetal.(11)presentedtheir1yearexperiencewithamodifiedWorld
HealthOrganization(WHO)neurosurgicalchecklistandcomparedtheinitial6monthsofchecklist
implementationwiththefollowing6months.Krameretal.(12),Lepanluomaetal.(19)andFargenetal.
(18),intheirstudieslasting1year,12weeksand8weeks,respectively,comparedequallyprolongedpre
checklistandpostchecklistperiods.In5papers(6,7,9,16,17),thestudytermswerenotdiscussed,nor
weretheeventualstudyphases.

Themostreliableresultscouldbeachievedbyserieswithmoreprolongeddurationscomparingpre
checklistandchecklistphases.Hopefully,futurestudiesinthisfieldwillcovertheseexpectations.

Numberofcases
Thenumberofallreportedcasessecuredbyneurosurgicalcheckliststodateisfewerthan20,000(519).
Oszvaldetal.(14)describedthebiggestserieswhichincluded12,390procedurescontrolledbyasafety
checklist.ThenextlargestwasthereportofLyonsetal.(8),covering6313cases.Therestofthepapers
included400orlessneurosurgicalcases,withthesmallestonebeingcomprisedofonly3procedures(16)
controlledbyasafetychecklist.

Thecomparisonbetweenaneurosurgicalchecklistappliedin3cases(16)withanotherchecklistusedin
over12,000procedures(14)wouldnotbemeaningfulandreliable.

Barrierstothechecklistimplementation
Onlyonereport(1/15)(13)presentedtheattendantbarrierstotheimplementationofneurosurgical
checklists.McLaughlinetal.(13)reportedthatnotallmembersactivelyparticipated,someelementswere
rushedandnotgivensufficientconsideration,thechecklistitselfwasnotreferredtoandsomeofits
elementswereskipped.Thefactthatthebarrierstoneurosurgicalchecklistimplementationwererarely
reportedshouldnotmisleadtheneurosurgicalcentersandcolleagueswhoshouldconsiderstartingto
applysafetychecklistsroutinelyintheirdailypracticesothattheprocessissmoothanduneventful.

Effortstothechecklistimplementation
Threeteams(3/15)(6,13,15)describedtheireffortswiththeimplementationoftheneurosurgical
checklists.NASS(6)postedthesafetychecklistintheoperatingroominahighlyvisiblearea.
McLaughlinetal.(13)useddirectobservation,regularevaluation,feedback,andoperatingroomhuddles
andreviewedtheprocessanditsimportanceduringdepartmentalmeetings.Rahmathullaetal.(15)
recommendedteamleaderspromotingandbuildingacultureofsafety,supportingstaffmembers,
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cultivatingeffectivecommunicationwiththepatientandteammembers,andusinglessonslearnedto
enhancesafetyandadvanceideastopreventfurthererrors.

Teamappreciation
Theteamappreciationoftheneurosurgicalchecklistisofutmostimportanceforitssuccessfulapplication.
Thiswasreportedin6outof15series(5,10,13,1719).Matsumaeetal.(10)believedthatthesafety
checklistmanagedtheconcernsandambiguitiesrelatedtotheprocedures,promotedteambuildingand
keptthesurgicalflowsmooth.McConnelletal.(5)consideredthechecklistasacommitmentto
improvedpatientsafety.AccordingtoMcLaughlinetal.(13)themajorityoftherespondentsintheir
studybelievedthatthesafetychecklistimprovedpatientsafety,thatteammemberintroductionshelpedto
promoteateamspiritandthattheylearnedsomethingnewaboutthepatientand/ortheprocedureduring
thetime,whichhelpedthemtoensurepatientsafety.Chenetal.(17)thoughtthattheneurosurgical
checklisthelpedteammemberstoremaincalmunderpressureandtofunctionefficientlyinacomplex
anddiresituation.Itgaveapossibilitytorecognizewhenoneneededtoimproviseorwhenoneshould
not.Fargenetal.(18)andLepanluomaetal.(19)believedthatthechecklistssignificantlyimprovedthe
teamcommunicationandwork.

Safetyoutcomes
Thequestionofthesafetyoutcomesisthemostimportantintheanalysisofneurosurgicalchecklists.

Ingeneralneurosurgery,Lyonsetal.(8)hadnocasesofincorrectsitesurgery,wrongprocedure,or
wrongpatientsurgery,whichwasregardedaninitiationofsafetyculture.DaSilvaFreitasetal.(11)
identified51eventsin44surgeriesandachievedthecorrectionof88%oferrorsbeforetheinitiationof
surgery.Oszvaldetal.(14),intheirseries,had1wrongsidedburrholeinanemergencycaseand1
wrongsidedlumbarapproachinanelectivecaseintheirstudyphase1(2(0.03%)errorsoutof6322
cases)andnoerrorsinphase2.McLaughlinetal.(13)didnotreportanyconcretesafetyoutcomedata
butobservedbettercommunication,collaboration,safetyattitudesandteambuildingexperience.
Lepanluomaetal.(19)achievedreductioninthewoundcomplicationsandunplannedreadmissions.
Matsumaeetal.(10)andRahmathullaetal.(15)withtheirownspeciallydesignedchecklistsfor
neurosurgicalproceduresperformedintoanintraoperativeMRIalsoreportednosafetyincidentsor
accidents.

Intheareaofstereotacticandfunctionalneurosurgery,Connollyetal.(7)reportedthatthetotalnumber
oferrorspercasedidnotchangesignificantly.However,thechecklistidentifiedandremediatederrors
duringDBSatthepriceofminimaladditionaloperativetime.Krameretal.(12)identifiedareductionin
thetotalnumberofmajorandminorerrorsfrom3.2to0.8totalerrorspercase.

Invascularneurosurgery,thechecklistofFargenetal.(18)resultedinasignificantreductionoftotal
adverseevents.

Inspinalneurosurgery,Ziewaczetal.(16)withtheirchecklistforintraoperativeneuromonitoringalerts
effectivelyidentifiedanestheticregimenchangesthatwereresponsiblefortheneuromonitoringwarnings.

McConnelletal.(5),withthechecklistdevelopedbythemfortheplacementofexternalventricular
drainage,achievedsubstantialreductionoftheventriculostomyinfectionrate.

In3papers(3/15),thesafetyoutcomewasnotreported(6,9,17).

CONCLUSION Goto:

Todate,theworldneurosurgicalexperiencewithchecklistsisquitelimitedcomparedtootherareasof
surgeryandintensivecaremedicine.Thereareonlyafewneurosurgicalcenterswithsignificant
achievementsinrespectofdurationofsafetychecklistapplicationandnumberofsecuredprocedures.
However,thesafetyoutcomesoftheneurosurgicalchecklists,regardingthepreventionofalltypesof
wrongsitesurgery,complicationsduetotheincorrectpositioningofpatientsforaneurosurgical
procedure,complicationsduetofailureofthedevicesrequiredforthespecificinterventionandsome
peculiarerrorstoaparticularneurosurgicalareaorsituation,areexcellentandencouraging.The
neurosurgicalchecklistsrepresentanefficient,reliable,costeffectiveandtimesavingtoolforincreasing
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201765 ChecklistsinNeurosurgerytoDecreasePreventableMedicalErrors:AReview

thepatientsafetyandelevatingtheneurosurgeonsselfconfidence.Theyareastepaheadinbuildinga
globalsafetycultureinneurosurgeryandassuchtheydeserveactiveattentionandtheeffortsof
internationalandnationalneurosurgicalsocieties.

Footnotes Goto:

EthicsCommitteeApproval:N/A.

InformedConsent:N/A.

Peerreview:Externallypeerreviewed.

ConflictofInterest:Noconflictofinterestwasdeclaredbytheauthor.

FinancialDisclosure:Theauthordeclaredthatthisstudyhasreceivednofinancialsupport.

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