Article Text

Download PDFPDF

Using checklists to improve patient safety during anaesthesia
  1. Alastair Mair


Background: It is inevitable that human errors will sometimes happen in practice, but these can be reduced by following some strict, straightforward checklists; these can serve as ‘aide-mémoires’, ‘challenge/response’ or ‘read and do’ checks, and are particularly important during the induction of, and emergence from, anaesthetic procedures.

Aim of the article: This article highlights the importance of checklists, and explores the comparison between human healthcare checklists and those used in veterinary medicine.

View Full Text

Statistics from

Embedded Image

Alastair Mair qualified from the University of Edinburgh in 2001. After several years in practice, he completed various internships and a residency in veterinary anaesthesia and analgesia at the University of Glasgow. He currently works at the Willows Veterinary Centre and Referral Service in Solihull. He was awarded diplomate status of the European College of Veterinary Anaesthesia and Analgesia in 2013.

Key learning outcomes

After reading this article, you should understand:

  • The importance of checklists to improve patient safety during anaesthetic procedures;

  • How checklists are designed and what objectives can be achieved by using them;

  • The key points of the World Health Organization’s surgical safety checklist;

  • The key points of the Association of Veterinary Anaesthetists anaesthetic safety checklist.

Errors and safety

Errors in anaesthesia are inevitable. Even the most experienced and skilled professionals can succumb to human error. Lienhart and others (2006) found that human error accounted for 51 to 77 per cent of all anaesthesia-related deaths in human healthcare. In one study of newly qualified veterinary graduates (individuals with less than five years in practice), 78 per cent admitted to making a mistake that affected a patient (Mellanby and Herritage 2004). Ten per cent of these failings were linked to anaesthesia-related errors.

McMillan and Lehnus (2018) demonstrated that safety incidents occurred at a rate of approximately one in every 20 anaesthetics at a university veterinary small animal teaching hospital. Safety incidents were defined as any event or circumstance which could have resulted, or did result, in unnecessary harm to an animal or to a member of staff.

In November 1999, the Institute of Medicine (IOM) released a report called ‘To Err is Human: Building a Safer Health System’ (IOM 2000). In response to its findings, a system-orientated approach to patient safety was recommended. Rather than treating errors as failings of an individual, the systems approach takes the view that most errors reflect predictable human failings as a result of poorly designed systems.

The intent of the IOM committee was to improve safety and quality of care by redesigning systems and processes in order to mitigate the effects of human factors (IOM 2001). In an effort to act on those recommendations, and to improve systems and processes, the medical profession observed those of other industries, such as aviation.

Introduction of checklists

Checklists were first introduced in aviation in the 1930s to address human error, as more sophisticated aircraft were built. In 1935, there was an investigation into a plane crash – it found that the pilot had omitted a crucial step during the preflight preparation that rendered the aircraft uncontrollable. Although the pilots involved were both highly qualified, the fatal error was still made.

Subsequently, a new approach to flight safety was required, and it took the form of a checklist of tasks which had to be completed before takeoff (Webster 2017).

Similarly to flying, anaesthetising an animal also represents a balancing act; a drug-induced reversible state must be achieved, consisting of unconsciousness, amnesia, antinociception and immobility, while maintaining physiological stability (Brown and others 2010).

Similarities also exist between pilots and anaesthetists; both are involved in long periods of relative inactivity and low cognitive load, interspersed with moments of extremely high tension (Higham and Baxendale 2017).

Checklist design

Checklists are intended to achieve the following objectives:

  • Serve as a memory aid;

  • Moderate the feelings of fatigue, stress and distraction;

  • Standardise the performance of tasks across users;

  • Ensure adherence to accepted or recommended best practices; and

  • Promote communication among team members (Chaparro and others 2019).

Checklists should be designed to improve patient safety by prompting checking and communication at crucial time points (Webster 2017); for example, during the induction of, and emergence from, anaesthesia. Non-essential activities which could contribute to adverse effects through distraction or confusion must be avoided (Broom and others 2011).

Checklists can be adopted in various formats. They may constitute a series of ‘read and do’ checks; for example, for checking a piece of equipment. They may be ‘challenge/response’ checks to confirm that procedures have been completed, or an ‘aide-mémoire’ to provide a series of structured prompts for a team briefing or debriefing (Winters and others 2009).

Checklist design requires consideration of content, format and timing. Implementation should include formal testing and evaluation. It is recommended that checklists should ideally be one page, use simple and familiar language, and take less than three minutes to complete. Each element should contain no more than five to nine items.

Checklists should also allow freedom for clinicians to use their clinical judgement (Hales and others 2008, Taylor and others 2010, Walker and others 2012). The checklist should be read out loud by one member of staff and the responses should be completed by another member of staff.

Checklists in human healthcare

In 2009, the World Health Organization (WHO) published the surgical safety checklist (SSC) as part of their ‘safe surgery saves lives’ campaign (WHO 2009). Since then, numerous studies (including several meta-analyses) have reported reductions in perioperative morbidity and mortality after implementation of the SSC (Haynes and others 2009, Borchard and others 2012, Bergs and others 2014, Gillespie and others 2014). Guidelines for safe surgery were published following a systematic review of the evidence available. Ten essential objectives for safe surgery were identified. These related to:

  • Identifying the correct surgery site;

  • Provision of safe anaesthesia;

  • Management of airway problems;

  • Management of haemorrhage;

  • Avoiding known allergies;

  • Minimising the risk of surgical site infection;

  • Preventing the retention of swabs and instruments;

  • Effective communication within the surgical team;

  • Accurate identification of specimens; and

  • Routine surveillance of surgical outcomes.

The WHO SSC (Fig 1) (available at contains three phases:

  • Before the induction of anaesthesia (with at least a nurse and anaesthetist present)

    • Patient identification;

    • Surgical site identification;

    • Anaesthesia equipment check;

    • Establish known allergies;

    • Establish airway management/risk;

    • Establish risk of blood loss.

  • Before the skin incision is made (with a nurse, anaesthetist and a surgeon present)

    • Team introductions;

    • Reconfirm patient, procedure and incision site;

    • Confirm antibiotic prophylaxis;

    • Discuss anticipated critical events;

    • Ensure imaging is displayed.

  • Before the patient leaves the operating room (with a nurse, anaesthetist and a surgeon present)

    • Check counts of instruments, sponges and needles;

    • Ensure specimens have correct labelling;

    • Discuss concerns for recovery.

Fig 1: The World Health Organization’s surgical safety checklist, published in 2009 as part of their ‘safe surgery saves lives’ campaign. This checklist is not intended to be comprehensive

The WHO explicitly states that ‘this checklist is not intended to be comprehensive. Additions and modifications to fit local practices are encouraged.’ The use of a modified version of the WHO SSC is now mandatory for all NHS trusts in England and Wales (Sivathasan and others 2010).

Checklists in veterinary medicine

In 2014, a study described the use of a simple safety checklist to prevent complications associated

with veterinary anaesthesia (Hofmeister and others 2014). Anaesthesia-related incidents were

logged over approximately a one-year period at a university veterinary teaching hospital.

Examples of these anaesthesia-related incidents included:

  • A closed adjustable pressure limit (APL) valve with the patient connected to the circuit;

  • Oesophageal intubation;

  • A drug given by the wrong route;

  • An incorrect drug given;

  • An incorrect dose of drug given; and

  • Catheter malfunction.

Subsequently, several changes were made to the anaesthetic record/protocol based on these results, such as reading out various components including;

  • The drug name;

  • The patient name; and

  • The route of drug administration before giving to the patient.

The authors found that the use of a checklist like this significantly reduced the number of anaesthesia-related adverse events.

The Association of Veterinary Anaesthetists checklist

The Association of Veterinary Anaesthetists (AVA) have devised a checklist and a number of recommended procedures in order to improve safety during veterinary anaesthesia. The objectives of the checklist are:

  • To outline an appropriate manner and order in which to perform key procedures in the anaesthetic process;

  • To improve teamwork and communication during the anaesthetic process; and

  • To reinforce recognised safe practices by ensuring critical safety steps are performed before moving between key points in the anaesthetic process.

The AVA checklist (Fig 2) is available online at and contains a checklist page and a recommended procedures page.

Fig 2: Association of Veterinary Anaesthetists safety checklist for anaesthesia. There are three phases to be considered: preinduction, preprocedure and recovery

The recommended procedures page lists preanaesthetic considerations, such as clinical examination findings, comorbidities, anticipated complications, anaesthetic drug choices, monitoring equipment and facilities required.

An anaesthetic machine section contains tick boxes to ensure equipment is functioning properly. There is also a drugs/equipment section that lists essential drugs and equipment that need to be made available, such as endotracheal tubes.

Additionally, there is a link to the reassessment campaign on veterinary resuscitation (RECOVER) initiative. This is an internationally recognised authority in veterinary cardiopulmonary resuscitation (CPR), providing guidelines, educational resources and updated scientific research regarding CPR.

The AVA checklist contains three main phases, with several items designated to each phase:

  • Preinduction

    • Confirm patient name, owner consent and procedure;

    • Confirm intravenous access and airway management;

    • Confirm equipment checks and the breathing system and ensure that the APL valve is open;

    • Confirm roles of team members;

    • Identify potential risks; and

    • Ensure emergency interventions are available.

  • Preprocedure

    • Reconfirm patient name and procedure;

    • Ensure depth of anaesthesia is adequate; and

    • Communicate safety concerns.

  • Recovery

    • Communicate safety concerns;

    • Confirm intervention plan;

    • Confirm analgesic plan; and

    • Confirm the person responsible for monitoring the patient.

The AVA has also published more extensive guidelines for safer anaesthesia, with the aim of increasing veterinary staff and owner awareness of the importance of good patient safety during anaesthetic procedures (see further reading).

Information is provided regarding patient safety, anaesthetic case planning, analgesia, staff, monitoring, patient support, emergency readiness, recovery, training and records. These resources are recommended by the RCVS’s practice standards scheme.

Barriers and facilitators to implementation

When implemented ineffectively, the use of checklists have failed to demonstrate clinical improvements (Sendlhofer and others 2018). Successes and failures in implementation reflect the complex challenges in patient safety and quality improvement (Catchpole and Russ 2015).

Success requires change to complex systems, processes and organisational culture, not merely just the presence of a checklist (Clay-Williams and Colligan 2015).

The implementation of checklists can be challenging due to a number of reasons including:

  • Poor communication;

  • Pragmatic challenges – for example, unfamiliarity and the time spent completing checklists;

  • Lack of leadership;

  • Lack of resources;

  • Attitudes – for example, dismissive behaviour;

  • Duplication of documentation; and

  • Lack of underlying processes of care – for example, routine swab counts (Fourcade and others 2012).

Menoud and others (2018) devised a veterinary anaesthetic safety checklist which was adapted from the WHO SSC. The authors then attempted multiple interventions in order to optimise implementation in a veterinary university small animal teaching hospital environment.

It was evident from these optimisation trials that effective checklist implementation hinges on:

  • Decisive and effective leadership;

  • Designating a person responsible for the checklist;

  • Encouraging active staff participation;

  • Regular audits; and

  • Educating the individuals using the checklist.

Taking these points into account, the finalised version of the checklist was short, straight-forward and comprehensive.


Patient safety should be at the forefront of everything we do as veterinary surgeons and veterinary nurses. A culture should be created which encourages the use of checklists and promotes non-technical skills, such as communication and team coordination, in order to reduce the likelihood of human error.

It is important that the whole team recognises the value of completing checklists rather than regarding them as a menial tick box exercise. When we board a plane, we expect that routine safety checklists will always be followed – the same should apply to our veterinary patients undergoing anaesthesia.


Further reading

View Abstract

Request Permissions

If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.