Implementing endoscopy checklists – a step in the right direction?

Concerns about safety and complications in endoscopy have risen to the fore in recent years, particularly with the introduction of endoscopic screening programs where asymptomatic patients are exposed to procedural risks. In 2004, The UK Report of National Confidential Enquiry into Patient Outcome and Death ‘Scoping our Practice’ was published, examining 1818 deaths from NHS and independent sector hospitals within 30 days of therapeutic endoscopic procedures. Worryingly, it identified that 24 % of endoscopic procedures were either inappropriate or futile [1]. Recommendations from the report focused on the areas of organizational structure, training and education, endoscopists’ technical skill, and patient information and monitoring. Checklists have been proposed as one means to improve patient safety.

Safety checklists have their origins in the aviation industry [2]. When Boeing was vying for a US government contract for World War II fighter planes, a fatal test flight crash occurred as a result of a basic human error: the pilot simply forgot to release the elevator locks. Subsequently, critics coined the phrase “too much plane for one man to fly,” highlighting the complexities of the human – technology interface [3]. Pilots discussed how to make sure “everything is done and nothing is overlooked’’ so that these oversights would not recur, and this process led to the concept of the safety checklist.

“...errors can occur at any stage from referral to post-procedure, and many errors arise from basic oversights…”

From their inception in the aviation industry in the 1930 s, safety checklists have been adopted in the healthcare setting. In 2009, a landmark study was published, which demonstrated the positive effect of checklists in the surgical setting, with an almost halved reduction in mortality from 1.5 % to 0.8 % (P = 0.003) [4]. Subsequently, the implementation of checklists has occurred in different settings in an effort to reduce “avoidable” errors [5] [6] [7] [8], with growing interest in their use in interventional procedures in gastrointestinal endoscopy [9]. In the UK, the Joint Advisory Group for Gastrointestinal Endoscopy requires that endoscopy services complete a safety checklist prior to all procedures and to audit its use [10]. In addition, the NHS England Patient Safety Domain published National Safety Standards for Invasive Procedures, which also requires all hospitals to perform checklists and audit to ensure compliance [11].

A checklist requires effective leadership and active engagement of all team members; there is a growing body of evidence linking teamwork to improved surgical outcomes [12] [13]. Checklists can perform as a “read-and-do” aide memoire, or a “challenge-response” (i. e. “has something been done?”) framework, although the method may be less important than the secondary gains of team cohesiveness through to exchanging information and unified goals to avoid error. To date, however, there is no firm evidence that their use in endoscopy is effective in improving safety and preventing error.

The study by Kherad et al. in this issue of Endoscopy examined safety checklist implementation involving all patients undergoing colonoscopy in an endoscopy unit in a Canadian tertiary referral centre [14]. The authors demonstrated a moderate adherence to checklist implementation (69.3 %), in over 1000 procedures over a 3-month period, showing feasibility of checklist adoption in this setting, albeit not universal. One could argue that the 30 % of procedures where no checklist was used were the procedures most likely to benefit – possibly because of poor leadership and team working, or where time pressures meant that corners were cut. In this current study, checklist adherence rates were lower for physicians compared with nursing colleagues (71.2 % vs. 84.0 %, respectively). This has been attributed to additional unjustified time and loss of autonomy, which are the main obstacles for physicians [15]. The authors plan to address this in the next step of the intervention “Plan-Do-Study-Act” approach.

Data collected through validated questionnaires completed by staff showed statistically significant improvements in the perception of team communication and teamwork after checklist implementation. However, as the study was based on uncontrolled time-series analyses, inferences of causality should be made with caution. No difference was demonstrated in terms of pre-procedure and safety outcomes; this may be attributable to sample size owing to the low incidence of such outcomes in routine colonoscopy. Thus, the effects of safety checklists on safety outcomes remain unclear. Population-based studies from Canada and Michigan, USA, have also failed to demonstrate their benefit with regard to complication rates and morbidity [16] [17].

Checklist use and effectiveness in emergency surgery emphasizes that they take minimal time to complete (under a minute), and hence, do not delay therapeutic intervention [18]. A checklist is not a mere “tick the box” exercise, but rather it calls for us to communicate and be engaged, working as a team to ensure safe practice for the patient. Interestingly, nurses’ initial scores for teamwork and team communication were lower than those of doctors [14]. The endoscopist and team may not meet the patient until moments before the procedure. With increased demand for complex therapeutic endoscopy, multiple clinicians are often involved in the process. A final check to ensure all critical information is shared is a simple way to avoid potential harm. Endoscopy-specific checklists ensure that all necessary equipment is available for each procedure planned, including the kit that would be needed in the event of complications.

Although routine endoscopy is inherently safer than surgery, it still carries a significant risk of serious harm and even death, and it is incumbent on us to strive to minimize patient harm. Improving safety and reducing errors requires a multi-disciplinary, multi-faceted systems approach: errors can occur at any stage from referral to post-procedure, and many errors arise from basic oversights. Checklists have been demonstrated to be effective in reducing harm in other clinical and nonclinical spheres; however, checklist use in endoscopy is in its infancy and it is perhaps too early to judge how effective they will be in improving endoscopy safety. Checklists are dynamic and need constant refinements – it is only through audit and research that current checklists will evolve toward the optimum. The study by Kherad et al. shows only moderate adherence over a short study period, albeit with improved perception of teamwork and communication. It stands to reason that checklists cannot work if they are not used – the question remains of how to maximize adherence across the team to ensure that the true potential for safety and outcomes can be recognized.

• References

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