Practice of Medicine


Barriers to the use of perioperative briefings and checklists

Several years ago, an article appeared in the New England Journal of Medicine (NEJM)1 which unveiled the development and implementation of a surgical checklist. This was demonstrated to reduce morbidity/mortality in a variety of international operating rooms. Since then, the use of this process in perioperative briefings has been widely adopted and is considered an important practice for improving patient safety.

The results, however, have not been uniformly dramatic and some barriers have arisen to the successful use of this practice. A study in the British Medical Journal (BMJ)2 outlined some of these barriers. In addition, one of the original authors of the NEJM study, Atul Gawande, has developed a “Checklist for Checklists” to address these issues (

At the outset, there are three conditions that are crucial for any change in a system to be successful:

  1. Recognition of the fact that medical care is complex, and no one provider can remember and be responsible for all processes;
  2. Good teamwork and communication is required for development of the new process; and
  3. All members must be committed to the success of the project, especially at the leadership level.

There are local factors unique to each environment which make the instillation of a generic template unlikely to succeed. Each checklist must be developed and implemented by that institution with input from those who will be responsible for using it.

The BMJ article identified barriers which can be anticipated: poor interchanges between surgeons and anesthesiologists, ambiguity regarding checklist items, lack of commitment reflected in gaming the system (e.g., checking off unchecked items at the end of the day) and lack of clarity in roles and responsibilities. The need for local development was displayed when providers felt that there was duplication with existing processes, and items on the checklist did not make sense or were excessively time-consuming.

COPIC believes that these obstacles can be overcome if the checklist for your institution is developed in a proactive manner, such as suggested by Gawande in his Checklist for Checklists. The process should be dynamic, and analyzed and changed appropriately in an ongoing manner by committed and enabled team members.

1 NEJM January 29, 2009 2 BMJ March 7, 2012

Created by MagMutual from materials provided by COPIC as part of MagMutual and COPIC’s alliance to improve patient safety and quality of care for all of our PolicyOwners.


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The information provided in this resource does not constitute legal, medical or any other professional advice, nor does it establish a standard of care. This resource has been created as an aid to you in your practice. The ultimate decision on how to use the information provided rests solely with you, the PolicyOwner.