Optimize timing of surgical safety checklist completion to account for exit from anesthesia

  • The World Health Organization introduced the Surgical Safety Checklist (SSC) in 2008 to improve the safety of surgical and anesthetic care, and the Canadian Patient Safety Institute has adapted it for Canadian practice .

  • The SSC consists of 3 phases, “sign-in”, “time-out” and “signout”, each designed to represent the important stages of the surgical operation.

  • Although the connect and disconnect phases are anchored at an appropriate clinical point in time, the timing of the disconnect phase is ambiguous and its completion variable.

  • The disconnection phase in the current SSC model does not assess the safety of patient emergence, which is the most critical step of anesthesia.

  • We propose to improve the surgical safety checklist to adequately account for patient discharge from anesthesia.

As part of the “Safe Surgery Saves Lives” initiative, the World Health Organization (WHO) launched the Surgical Safety Checklist (SSC) in 2008, aimed at addressing important surgical safety issues and poor communication between members of the operating team.1 In 2009, the Canadian Patient Safety Institute (CPSI) used the WHO SSC as the basis for its own 19-point SSC that would best fit to Canadian standards of care and lay the foundation for local practices2 (available at https://www.patientsafetyinstitute.ca/en/toolsResources/pages/surgicalsafety-checklist-resources.aspx). Between January and June 2021, 98.5% of surgeries in Ontario reported completing the checklist3. While surgical checklists have undoubtedly improved the safety of surgeries, SSC misses a key part of the surgical continuum because it is completed before the patient leaves the operating room. bedroom. We offer an additional checklist item to cover discharge from anesthesia and further increase patient safety.

The SSC was adapted from checklists used in the airline industry. Pilots complete a series of checklists throughout several phases of a flight, including preflight, takeoff, approach and landing. These phases are analogous to the phases defined in the SSC. Similar to the pre-flight phase, the “sign-in” or “briefing” checklist is completed when the patient enters the operating room prior to induction of anesthesia, where the patient’s identity, procedure surgery and the incision site are confirmed. The “timeout” phase occurs just before the incision is made and is analogous to the taxi and takeoff phase in a flight checklist, as it is the last opportunity to examine the site and the planned procedure and to anticipate critical events. The final phase, “sign-out” or “debriefing”, corresponds to the landing phase of a flight, occurring before or when the patient leaves the operating room.1 The sign-out phase includes an examination of procedure, significant intraoperative events, fluid management, instrument count, specimen labeling and management, and recovery plans, including postoperative ventilation, pain management, and temperature.2 This phase includes 3 final questions: “Modifications of the postoperative destination? », « What are the main concerns? for the recovery and care of this patient? and “Could something have been done to make this case safer or more efficient?” »2

The disconnection phase must be completed “before the patient leaves the operating room”.1,2 Unlike the connect and timeout phases, where the time of completion is clear, final, and anchored to a specific clinical moment, the disconnect can be done any time before the patient leaves the operating room – even before the emergence of anesthesia. This creates the potential for miscommunication of critical events when discharging a patient from anesthesia.

The risks of anesthetic complications are highest in the final phase of anesthesia.4,5 Disconnecting before the patient fully emerges from anesthesia is equivalent to signaling a safe landing while the aircraft is still on final approach. If the disconnect phase is to consider the safety of the patient’s entire intraoperative journey, from entry to exit, then ask if “anything could have been done to make this case safer or more efficient”2 before that the patient does not wake up from the anesthesia is not enough. make sense.

Quality improvement work has shown that compliance with SSC debriefing is also the lowest among the 3 phases of SSC.6,7 Staff often do not know when and where to debrief and often have competing clinical priorities.6,7 In order to address compliance, reliability, and ambiguity of the timing of the disconnect phase, the University Health Network in Toronto — the largest health care research organization and network of teaching hospitals in Canada — recently implemented changes to their local SSC. Rather than specifying that disconnection must be completed before the patient leaves the operating room, the new checklist defines the clinical time at which disconnection must be completed; that is, before the skin closes. However, this change fails to capture all adverse events related to exit from anesthesia, thus compromising the usefulness of SSC to act as a tool to systematically capture and communicate critical information throughout the surgical journey of a patient.

To capture data related to anesthetic emergence, we suggest 2 possible modifications to the SSC. The first is to expand the current SSC to include a fourth and final phase, the “sign-off” phase, to be completed after the emergence of anesthesia, at which time the intraoperative surgery, anesthesia and nurses will be able to assess the safety of the surgery. procedure in its entirety. Questions related to the emergence and overall safety of the procedure can then find a reliable and precise answer. Adding a fourth phase to the checklist would increase complexity by introducing another commitment, and operating room staff may view this addition as a time-consuming increase in workload, which can hurt engagement and compliance.6,8 The addition of this fourth phase – characterized by the debriefing of the surgeon, nurse and anesthetist in the post-anaesthesia care unit – has however been associated with improvements in compliance, attendance of team members and active participation.9 To alleviate any perceived burden, the questions asked during the sign-off phase could be simplified. Open-ended questions require qualitative information gathered through focused discussion, which can reduce team member engagement.10 Questions such as What are the main concerns for the recovery and management of this patient? could be replaced by “Are there any recovery concerns?”

The second option is to anchor the logout to a specific event. Several different clinical entry points for disconnection have been discussed and studied, including completion of the first swab and instrument count,11 during or immediately after skin closure,12 before final suturing,13 or after transfer of the patient from the operating table to the transport trolley. 9 However, the anchoring of disconnection to anesthetic emergence has not been studied. While we recognize that delaying exit from anesthesia after emergence from anesthesia may limit a surgeon’s ability to leave the operating room to speak to a patient’s family members, there are often sufficient turnaround time between the end of one operation and the start of the next to complete this and other tasks.

Several factors, including organizational context, culture and community, will ultimately dictate how SSC is implemented and the level of vendor compliance. Adding a disconnection phase, anchoring disconnection to emergence from anesthesia, or any other organic approach that best fits local practice can improve overall safety. Only then can the success of the operation be reliably and accurately assessed, and the safety data driven by SSC be considered truly valid.


The authors thank Mr. Mohamed Salem for his invaluable help in preparing background information for this manuscript.


  • Competing interests: None declared.

  • This article has been peer reviewed.

  • Contributors: All authors contributed to the conception and design of the work, drafted the manuscript, critically revised it for significant intellectual content, gave final approval to the version for publication, and agreed to be responsible of all aspects of the job.

  • Funding: Braeden Page is supported by the Canadian Institutes of Health Research through the Frederick Banting and Charles Best Canada Graduate Scholarship – Masters (CGS-M). Richard Brull receives research time support from the Evelyn Bateman Cara Operations Endowed Chair in Ambulatory Anesthesia and Women’s Health, Women’s College Hospital, and Merit Award Program, Department of Anesthesia and Pain Medicine, Toronto, Ont.

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Christine E. Phillips