The Checklist – Sign Up Or Lose

by Dr. Blake Nicolucci, BSc, DDS

Dental implants can be a challenge at the best of times, although if everything is planned out ahead of time, most of these challenges can be either overcome or eliminated. One of the best ways to overcome these challenges is to have an orderly list, one in which every facet of the proposed surgery or prosthetic rehabilitation has been carefully examined ahead of time – in an orderly fashion – a ‘checklist’ if you will. While preparing the new Implant Guidelines for the Royal College of Dental Surgeons, numerous other ‘guidelines’ were used from around the world. One thing that became evident to me was that nearly every guideline we referenced made use of a checklist as a tool to overcome or eliminate potential problems before they arose – or at least give direction when unsuspecting problems presented themselves (even after careful scrutiny of the situation beforehand). Just as an airline pilot uses a checklist for every facet of the flight he is planning to take, the implant dentist should also use a checklist (for each phase of treatment) to eliminate some of the pitfalls that are easily avoidable. This will mean that not only the basic points that need to be addressed are addressed, but it also prevents obvious items from being overlooked.

For example, even though a specific pilot has flown an aircraft for thousands of hours, it would be virtually impossible for him to remember each and every time all of the procedures required prior to a flight. For example, the ‘walk around’; to physically check the outside of the plane for loose gas caps, locked doors, leaky brake fluid, hydraulic fluids, gas leaks, tire pressures, and the full deflection and movement of all of the operational components required when flying, and also the ‘run-up’; starting the engines, testing the mobility of the rudder, ailerons and brakes; checking the fluid and temperature levels; making sure the plane’s throttle cables are all connected and have a full range of motion; and checking the radio frequencies – not only for communication, but for in-flight navigation. After both the walk around and the run up, there is: ‘take off’, ‘climb’, ‘level flight’, ‘descent’, ‘landing’ and ‘post landing’ checks. Now, I’ve given you the walk around and run up lists off the top of my head, and although I have hundreds of hours of flying time, I can tell you almost positively that I’ve missed at least one point that, even though small, should have been examined before becoming airborne. That one small item could spell disaster. Pilot ‘checklists’ are the only reason there are pilots who have logged thousands of hours in their aircraft. Nearly all pilots I know are not bold enough to just jump in an aircraft, start it up and take off. There is an old saying amongst pilots: “there are old pilots, and there are bold pilots, but there are no old-bold pilots”.

Just as the pilot must have situational awareness when flying, so must the implant dentist when proceeding with implant treatment on a patient. In terms of a pilot, situational awareness is described as a person having “awareness of their surroundings, the meaning of their surroundings, and what these surroundings will mean in the future – and then using this information to act”. And so it is for the implant dentist–you must have a specific goal, a well thought out treatment plan, the educational background to carry out the treatment, and a group of backup plans – for any number of complications that might arise during the treatment. The goal you have set may be ideal, but the patient should be aware of any possible complications that might arise. The patient should also be informed of any costs that might be incurred should any of these complications need to be addressed. The old adage – ‘inform before you perform’ should definitely be on your checklist of things to do before you begin treatment. The ‘look, think and act’ idiom is critical. Just as a pilot’s attention, perception and decision making form a mental model of the current situation, so it should be with the implant dentist.

Implant dentistry has grown and developed since it was established as a viable treatment option back in the 1970s, and the research has given us direction as to what works, what doesn’t, what is acceptable, and what is not. It is undeniable that the use of checklists (however mundane this may seem to neophytes) is an easy way to ensure that pre-operative, surgical, and post-surgical protocols are followed as required. It is not acceptable to wing it any longer. The rules have been written. Unfortunately (or fortunately – depending on how you look at it), implant dentistry has been assimilated in nearly every area of dentistry; general practitioners, prosthodontists, periodontists, orthodontists, oral surgeons, and now even endodontists. Although most of these are specialty fields, everyone should use a checklist.

Very special thanks to Dr. Peter Birek for putting me onto the book ‘The Checklist Manifesto’ by a surgeon named Dr. Atul Gawande. His basic premise is that people make two different kinds of errors: those of ignorance (in that we don’t know enough) and errors of ineptitude (not using what we actually know properly) and how we are most likely to fall into the second category – ineptitude. Life is becoming more complicated, and with tasks becoming more complicated, errors and omissions are being made not from ignorance, but from forgetting the basics and lack of memory recall, thus the ‘checklist’. Even in medicine, and especially in surgery, checklists are becoming more the standard of care (i.e. counting sponges and instruments on completion of surgery to make sure everything is accounted for). The medical field has learned quite a lot from the aviation industry. A checklist was developed for doctors when they were inserting central lines. The simple five point checklist was:

1. Doctors must wash their hands with soap for a full three-minute scrub.

2. Clean the patients’ skin with chlorohexidine.

3. Place sterile drapes over the entire patient.

4. Wear a mask, hat, sterile gown and gloves.

5. Place a sterile dressing over the insertion site.

After huge success in one hospital, this checklist was implemented in all hospitals across Michigan. In the first 18 months, the central line infection rate in Michigan’s ICU’s decreased by 66 percent and the hospitals saved an estimated $175 million in costs and more than 1500 lives. This was because of a “stupid little checklist”.

Dental implant surgery is really no different and has many important responsibilities attached. There are numerous checklists in the guidelines (which can be easily accessed, and so there is no need to repeat them here) and the reasons for these should now be much easier to understand. Having backup equipment so that surgeries can be completed when something unforeseen (like a hand-piece or motor not functioning properly) happens. Or back up implants (a larger implant may be needed if after bone preparation, the implant has some micro-movement visible) so that the surgery can continue with an implant of the appropriate size substituted for the original – all because each situation had been thought out ahead of time. These things actually happened to me (albeit over 25 years ago). This does not happen now (nor should it) since my staff has confirmed that all of the T’s were crossed and I’
s dotted ahead of the surgery. It would be very unfortunate to simply close up the patient and to bring them back at a later date, so that we had the necessary equipment/implants to complete the case. When the implant host site presents with insufficient bone (after reflection of the soft tissues) for implant placement, or there is pathology that has gone unnoticed, both of these situations could have been eliminated with the use of a CBCT scan prior to surgery. These scenarios won’t happen with the use of a simple checklist. Gawande thinks that “the modern world requires us to revisit what we mean by expertise: that experts need help, and that progress depends on experts having the humility to concede that they need help.” I couldn’t agree more. The premise of the book is that it’s not just the major items that contribute to a successful surgery, but it’s the small items that – if overlooked – can derail the ultimate success of the surgery. Very trite things can have dire consequences if they are overlooked.

The idea of the importance of a checklist is not so much that we will miss the obvious items, but that the small omissions can have catastrophic consequences. As I have discussed above, the failure to use a CBCT scan could produce an abysmal situation during surgery when we find something that should have been known well in advance. But what about something as simple as forgetting to make sure the patient has an escort to take them home? If they were to get outside and stumble, or faint and get hit by a car, how successful was the surgery then? A little melodramatic, yes, but it illustrates how small omissions have devastating consequences. Talk about post-surgical complications!

It’s difficult to get into the habit of using a checklist when you feel like, “I didn’t use it before, so I don’t need it now!” The problem being that you might have been ‘just lucky’ before, and you got away with omitting a point or two. The problems arise when you aren’t just lucky, the surgery goes south, your patient is suffering and you’re looking at years of litigation, psychological stress, and time away from the office. That’s when you realize the importance of a checklist. Don’t wait until it’s too late – DO IT NOW!OH

Dr. Blake Nicolucci, BSc, DDS, is president of the Canadian Society of Oral Implantology and is Oral Health’s editorial board member for Implantology.