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doi: 10.1097/ALN.0b013e3182887547
Education: Images in Anesthesiology

Images in Anesthesiology: The Preoperative Stop/Go Sign

Connor, Christopher W. M.D., Ph.D.; Gonzalez, R. Mauricio M.D.

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Checkpoints enhance patient safety by raising critical issues into the clinician’s conscious thought.1 Universal protocols and checklists help but may become rote and be bypassed,2 especially when compliance is insufficiently engaging or inconspicuous. The Preoperative Stop/Go Sign is a highly visible, interactive checklist (fig.). A layer of adhesive stickers forms a red “STOP” sign, covering a backing sheet showing a green “GO” sign. As each preoperative step is completed, the associated sticker is removed. Whoever removes the sticker can sign underneath, such that when the patient is ready for the operating room, each box on the “GO” sign contains a signature attesting to completion of that step. Stickers peel away individually; several steps cannot be “checked off” simultaneously. As the sign transforms, it illustrates clearly the patient’s progression to readiness; a visual motif that informs and includes even non–English-speaking patients and their families. The operating room staff can assess the signs from a distance, making the occurrence and cause of preoperative delays apparent and allowing earlier intervention. When all tasks are completed, the GO sign can be placed in the medical record as documentation. The sign is single use.
The sign adopts the DO-CONFIRM checklist style, encouraging concurrent task execution and featuring lean, pragmatic steps. The sign’s physical structure mitigates well-characterized real-world checklist failure modes,3 including “short-cutting” (multiple steps are performed and then checked off together, often with a single line) and “lack-of-completion” (the preoperative checklist is accepted as completed but contains omissions). The checkpoints were derived from a preexisting in-house checklist; alternative derivations from externally validated checklists may be beneficial.
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Competing Interests

The authors declare no competing interests.
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1. Ely JW, Graber ML, Croskerry P. Checklists to reduce diagnostic errors. Acad Med. 2011;86:307–13

2. de Saint Maurice G, Auroy Y, Vincent C, Amalberti R. The natural lifespan of a safety policy: Violations and system migration in anaesthesia. Qual Saf Health Care. 2010;19:327–31

3. Degani A, Weiner EL. Cockpit checklists: Concepts, design, and use. Hum Factors. 1993;35:28–43

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