Which hip is being repaired? Is this the right anesthesia? Do we have all the right surgery tools?
Answering such basic questions from surgery checklists _ and involving everyone as a team, even patients _ saved lives in Veterans Affairs hospitals, according to one of the most rigorous studies of patient safety in the operating room.
Surgery deaths dropped 18 percent on average over three years in the 74 VA hospitals that used the strategy during the study. Surgery team members all created checklists and discussed them in briefings before, during and after surgery. That's a somewhat novel concept in a setting where the surgeon has traditionally called all the shots.
The study found that death rates were lowest where surgical staff had the most teamwork training.
Dr. Peter Pronovost, a Johns Hopkins professor and author of a book on using checklists in medicine, called the VA results impressive.
"Teamwork problems are ubiquitous in health care but in operating rooms, they're so problematic because ORs are so hierarchical. They're full of ritual and for so many years it's been the surgeon (who) dictates," Pronovost said.
The VA's program began in 2003 and over time has been adopted at virtually all of its 130 surgery centers. Before sedation, patients identify themselves and the reason for their surgery, hear the checklists being read off, and can speak up if something doesn't sound right. The idea is to give everyone in the operating room an equal voice in helping ensure patient safety.
That is not standard procedure.
"I've heard surgeons say to nurses, 'Do you have an MD after your name? I didn't think so. So when you get one, I'll listen to you but until then, shut up,'" said the study's senior author Dr. James Bagian, former VA patient safety director.
He and his colleagues analyzed three years of data, from 2006-08, at 74 hospitals trained in the patient safety methods, compared with 34 similar centers where the program hadn't been implemented. The study included almost 200,000 surgeries.
The number of patients who died dropped from 17 per 1,000 surgeries each year before the program began to 14 per 1,000 surgeries per year afterward at the trained hospitals.
There was virtually no change in deaths at the untrained hospitals, which also numbered 14 per 1,000 surgeries at the study's end. Bagian expects the death rate at those hospitals will decline or may have already as the new surgery approach has become entrenched throughout the VA system.
The study appears in Wednesday's Journal of the American Medical Association.
Checklist-style approaches have been tried at other hospitals but the VA system is among the largest.
Several experts not involved in the research called the study robust and praised the findings.
Bagian, an engineering specialist at the University of Michigan, anesthesiologist and former NASA astronaut, helped devise the VA program, borrowing aviation techniques. At NASA in 1986, he had been set to fly on the Challenger space shuttle until a last-minute schedule change that saved his life. When the shuttle exploded after launch, he ended up deep-sea diving for remains of the seven crew members killed.
He said the teamwork-checklist approach "makes good common sense" and called the study results heartening.
Bagian said the openness the program encourages helped the VA uncover serious problems at a southern Illinois VA hospital a few years ago. Hospital staffers revealed concerns that helped launch an investigation that made national headlines: 19 patients at the Marion medical center had died after getting substandard or questionable care. A surgeon resigned in August 2007, and all major surgeries were suspended and remain on hold.
A VA report released earlier this month said conditions at the Marion hospital have since improved substantially.