Implementation of a checklist before colonoscopy: a quality improvement initiative
submitted 01 June 2017
accepted after revision 14 September 2017
13 December 2017 (eFirst)
Background and study aims Checklists can prevent errors and have a positive impact on patient morbidity and mortality in different surgical settings, and possibly also in gastrointestinal endoscopy. The aims of this study were to reinforce commitment in safety culture and better communication among team members in endoscopy, and to prove the feasibility of successful checklist adoption before colonoscopy.
Patients and methods The study involved a pre – post quality improvement intervention involving all consecutive patients undergoing a colonoscopy at a single academic endoscopy unit. The first part of the study was a retrospective audit, carried out over a 3-month period (July to September 2016). A checklist developed through a formal validation process was implemented during the intervention period (October to December 2016). Primary outcomes were changes in patient and team satisfaction after the quality improvement intervention, using validated 5-point scale questionnaires. Secondary outcomes included successful procedure completion rates and safety outcomes.
Results During the baseline and comparative intervention period, 1317 and 1141 colonoscopies, respectively, were performed. Overall, checklists were fully completed by nurses and physicians for 791 patients (69.3 %). Mean overall patient satisfaction was high at baseline and did not differ following the quality improvement intervention (4.66 vs. 4.63; P = 0.5). Perception of team communication and teamwork was improved after checklist implementation. Comparative analyses of per-procedure and safety outcomes did not differ between the pre- and post-checklist implementation.
Conclusion Adoption of an endoscopy checklist before colonoscopy is feasible, and significantly increases perception of team communication and teamwork. Additional studies are needed to assess the generalizability of these results to complex endoscopic procedures and to characterize any improvement in patient safety outcomes.
* These authors contributed equally to this work.
- 1 Kohn LT, Corrigan JM, Donaldson MS. , eds. To err is human: building a safer health system. Washington (DC): National Academies Press (US); 2000 ; 1999
- 2 World Health Organization. WHO guidelines for safe surgery: safe surgery saves lives. Available from: http://www.who.int/patientsafety/safesurgery/en/ Accessed: October 2017
- 3 Haynes AB, Weiser TG, Berry WR. et al. A surgical safety checklist to reduce morbidity and mortality in a global population. New Engl J Med 2009; 360: 491-499
- 4 Ko HC, Turner TJ, Finnigan MA. Systematic review of safety checklists for use by medical care teams in acute hospital settings – limited evidence of effectiveness. BMC Health Services Research 2011; 11: 211
- 5 Treadwell JR, Lucas S, Tsou AY. Surgical checklists: a systematic review of impacts and implementation. BMJ Qual Saf 2014; 23: 299-318
- 6 Borchard A, Schwappach DL, Barbir A. et al. A systematic review of the effectiveness, compliance, and critical factors for implementation of safety checklists in surgery. Ann Surg 2012; 256: 925-933
- 7 World Health Organization. Patient safety: surgical safety Web map. Geneva. Available from: http://maps.cga.harvard.edu/surgical_safety/ Accessed: October 2017
- 8 Kearns RJ, Uppal V, Bonner J. et al. The introduction of a surgical safety checklist in a tertiary referral obstetric centre. BMJ Qual Saf 2011; 20: 818-822
- 9 Rizk MK, Sawhney MS, Cohen J. et al. Quality indicators common to all GI endoscopic procedures. Gastrointest Endosc 2015; 81: 3-16
- 10 Matharoo M, Thomas-Gibson S, Haycock A. et al. Implementation of an endoscopy safety checklist. Frontline Gastroenterol 2014; 5: 260-265
- 11 Gavin DR, Valori RM, Anderson JT. et al. The national colonoscopy audit: a nationwide assessment of the quality and safety of colonoscopy in the UK. Gut 2013; 62: 242-249
- 12 Matharoo M, Sevdalis N, Thillai M. et al. The endoscopy safety checklist: a longitudinal study of factors affecting compliance in a tertiary referral centre within the United Kingdom. BMJ Qual Improv Rep 2015; 4: pii: u206344.w2567
- 13 Bohmer AB, Wappler F, Tinschmann T. et al. The implementation of a perioperative checklist increases patients’ perioperative safety and staff satisfaction. Acta Anaesthesiol Scand 2012; 56: 332-338
- 14 Kherad O, Restellini S, Martel M. et al. Polyethylene glycol versus sodium picosulfalte bowel preparation in the setting of a colorectal cancer screening program. Can J Gastroenterol Hepatol 2015; 29: 384-390
- 15 Romagnuolo J, Flemons WW, Perkins L. et al. Post-endoscopy checklist reduces length of stay for non-variceal upper gastrointestinal bleeding. Int J Qual Health Care 2005; 17: 249-254
- 16 Pronovost P, Goeschel C. Improving ICU care: it takes a team. Healthc Exec 2005; 20: 14-16 , 18, 20 passim
- 17 Leape LL. The checklist conundrum. New Engl J Med 2014; 370: 1063-1064
- 18 O’Daniel M, Rosenstein AH. Professional communication and team collaboration. In: Highes RG. ed. Patient safety and quality: an evidence-based handbook for nurses. Rockville (MD): Agency for Healthcare Research and Quality (US); 2008: 9-11
- 19 [Anonymous]. The Joint Commission guide to improving staff communication. Available from: www.jcrinc.com/assets/1/14/GISC09_Sample_Pages1.pdf Accessed: October 2017
- 20 Mazzocco K, Petitti DB, Fong KT. et al. Surgical team behaviors and patient outcomes. Am J Surg 2009; 197: 678-685
- 21 Davenport DL, Henderson WG, Mosca CL. et al. Risk-adjusted morbidity in teaching hospitals correlates with reported levels of communication and collaboration on surgical teams but not with scale measures of teamwork climate, safety climate, or working conditions. J Am Coll Surg 2007; 205: 778-784
- 22 Bergs J, Hellings J, Cleemput I. et al. Systematic review and meta-analysis of the effect of the World Health Organization surgical safety checklist on postoperative complications. Br J Surg 2014; 101: 150-158
- 23 van Klei WA, Hoff RG, van Aarnhem EE. et al. Effects of the introduction of the WHO “Surgical Safety Checklist” on in-hospital mortality: a cohort study. Ann Surg 2012; 255: 44-49
- 24 Urbach DR, Govindarajan A, Saskin R. et al. Introduction of surgical safety checklists in Ontario, Canada. New Engl J Med 2014; 370: 1029-1038
- 25 Reames BN, Krell RW, Campbell Jr. DA. et al. A checklist-based intervention to improve surgical outcomes in Michigan: evaluation of the Keystone Surgery program. JAMA Surg 2015; 150: 208-215
- 26 Bosk CL, Dixon-Woods M, Goeschel CA. et al. Reality check for checklists. Lancet 2009; 374: 444-445
- 27 Bliss LA, Ross-Richardson CB, Sanzari LJ. et al. Thirty-day outcomes support implementation of a surgical safety checklist. J Am Coll Surg 2012; 215: 766-776
- 28 Neily J, Mills PD, Young-Xu Y. et al. Association between implementation of a medical team training program and surgical mortality. JAMA 2010; 304: 1693-1700
- 29 de Vries EN, Prins HA, Crolla RM. et al. Effect of a comprehensive surgical safety system on patient outcomes. New Engl J Med 2010; 363: 1928-1937