Perioperative Safety in Plastic Surgery: Is the WHO Checklist Useful in a Broad Practice?

Background: In October 2007, the World Health Organization (WHO) instituted the Safe Surgery Saves Lives Program, the cornerstone of which was a 19-item safe surgery checklist. Based on a cohort of more than 3,000 consecutive surgery patients before and after the implementation of the checklist, death rates and inpatient complications decreased significantly, as did rates of surgical site infection and wrong-sided surgery. Based on these impressive reductions in complications and mortality, our institution joined others in adopting the WHO checklist in April 2009, with additional core measures added.  No specific additions or alterations were made specific to surgical sub-specialties.   Our purpose is to evaluate the efficacy and applicability of the WHO checklist in multi-surgeon plastic surgery hospital-based practice, by analyzing the effect its introduction had on complication rates and outcomes.

Methods: A retrospective review of the morbidity and mortality data from the Department of Plastic Surgery at Loma Linda University Medical Center was conducted from 2005 to 2011. Data on morbidity and mortality before and after implementation of the WHO checklist was analyzed in 4,476 plastic surgery cases.

Results: The most common unacceptable outcomes were wound-related, including infection, seroma, hematoma, dehiscence, and flap-related complications. Unfortunately, no significant decrease in the measured complications occurred after the implementation of the WHO checklist. Although verifying appropriate administration of antibiotic, presence of appropriate equipment and materials, performing a preoperative formal pause, and verifying the execution of the other measures included in the checklist are critical, , untoward outcomes after implementation of the checklist did not measurably decrease. In its current form as this time, the checklist does not appear to be effective in reducing perioperative morbidity in Plastic Surgery. We propose a multi-phase patient safety checklist tailored to a plastic surgery ambulatory care setting, which would target the entire surgical experience, from the initial consultation through the post-operative follow-up care. This checklist incorporates evidence-based interventions, targeting both the most common intradepartmental unacceptable outcomes and the most frequently encountered complications, as published in plastic surgery literature (Figure 1).

Conclusion: While certain elements of the WHO checklist are universal and should be adopted, certain specific aspects require modification to improve applicability in a plastic surgery-specific practice. This necessitates the creation of an ambulatory, surgical safety checklist specifically for plastic surgery.