Checklists

Checklists

Checklists

In Action

In Action

In Action

The Power of Checklists In Healthcare and Beyond

The Power of Checklists In Healthcare and Beyond

The Power of Checklists In Healthcare and Beyond

In complex systems, it takes multiple layers of defense to truly protect against errors.

Navigating Risks and Safety Layers In Surgery

Imagine standing in the pouring rain, equipped with all the rain gear you can think of—umbrella, hat, raincoat, and even shelter under a roof. Despite these layers of protection, there are moments when the rain manages to find a way in, perhaps due to a gust of wind or small openings in your gear. This situation is analogous to what James Reason termed the Swiss Cheese Model, illustrating that even with multiple safety measures, vulnerabilities can align, leading to mistakes.¹²

In critical environments like hospitals, where safety is paramount, the Swiss Cheese Model is utilized to comprehend and prevent errors. One specific tool derived from this understanding is the Surgical Safety Checklist—a tool designed to prevent errors and ensure a high level of safety. It's akin to systematically addressing potential holes in the Swiss cheese to create a more secure and reliable system.

The Making
Of The Checklist

The Nurses' Checklist

Nurses developed patient charts and forms that incorporated the monitoring of four vital signs: body temperature, pulse, blood pressure, and respiratory rate. These tools enabled them to track their patients' health status by regularly checking and evaluating vital signs every six hours. This system helped ensure that patients received timely and appropriate medical attention when necessary.⁵

Peter Pronovost's Checklist

Critical care specialist Peter Pronovost introduced a checklist system at Johns Hopkins Hospital's ICU. The system included five simple steps that nurses could use to observe doctors and stop them if they skipped a step. This collaborative approach allowed for effective communication between medical professionals and resulted in a remarkable outcome. Within a year, infections dropped from 11% to 0%, preventing 43 infections and eight deaths and saving the hospital $2 million in costs.⁵

THE MICHIGAN KEYSTONE ICU Project

The Keystone Initiative in Michigan utilized a checklist system to enhance patient safety in ICUs. Each participating hospital rolled out the checklist and observed the results with Peter Pronovost's supervision. Within three months, the infection rate in Michigan's ICUs dropped by 66%, saving more than 1,500 lives and reducing costs by roughly $175 million.¹²

SAFE SURGERY SAFE LIVES

To enhance patient safety and implement safer surgical procedures, a global research team led by Atul Gawande launched a project aimed at reducing adverse events in both operating rooms and wards. The team selected eight hospitals worldwide. This initiative reflects the importance of a global approach to patient safety, utilizing evidence-based practices and collaboration to improve outcomes in healthcare settings worldwide.⁹

🌐 NEWS!

2009

50%

A reduction in mortality was observed across the eight hospitals during the WHO's initial research.¹⁰

THE OFFICIAL CHECKLIST

After extensive research spanning several years, the World Health Organization developed a surgical safety checklist in 2009 that healthcare workers worldwide use in their operating rooms today. This standardized and universal checklist has become an essential tool for ensuring patient safety during surgical procedures, reflecting the WHO's commitment to improving healthcare outcomes globally.¹⁰

🇺🇸 NEWS!

2010

22%

A relative reduction in postoperative mortality was observed after the implementation of the Checklist in South Carolina.¹⁰

🇮🇷 NEWS!

2011

57%

A reduction in surgical complications was observed in a 374-bed hospital after using the Checklist in Iran.¹⁰

🏴󠁧󠁢󠁳󠁣󠁴󠁿 NEWS!

2019

36%

A reduction in post-surgical deaths was observed since the introduction of the Checklist in Scotland.¹⁰

WORLDWIDE IMPACT

As of 2019, the WHO's checklist is utilized in 70% of operating rooms worldwide, with over 20 countries adopting it as their national standard.¹⁰

The Making
Of The Checklist

The Making
Of The Checklist

The Nurses' Checklist

Nurses developed patient charts and forms that incorporated the monitoring of four vital signs: body temperature, pulse, blood pressure, and respiratory rate. These tools enabled them to track their patients' health status by regularly checking and evaluating vital signs every six hours. This system helped ensure that patients received timely and appropriate medical attention when necessary.⁵

The Nurses' Checklist

Nurses developed patient charts and forms that incorporated the monitoring of four vital signs: body temperature, pulse, blood pressure, and respiratory rate. These tools enabled them to track their patients' health status by regularly checking and evaluating vital signs every six hours. This system helped ensure that patients received timely and appropriate medical attention when necessary.⁵

The Nurses' Checklist

Nurses developed patient charts and forms that incorporated the monitoring of four vital signs: body temperature, pulse, blood pressure, and respiratory rate. These tools enabled them to track their patients' health status by regularly checking and evaluating vital signs every six hours. This system helped ensure that patients received timely and appropriate medical attention when necessary.⁵

Peter Pronovost's Checklist

Critical care specialist Peter Pronovost introduced a checklist system at Johns Hopkins Hospital's ICU. The system included five simple steps that nurses could use to observe doctors and stop them if they skipped a step. This collaborative approach allowed for effective communication between medical professionals and resulted in a remarkable outcome. Within a year, infections dropped from 11% to 0%, preventing 43 infections and eight deaths and saving the hospital $2 million in costs.⁵

THE MICHIGAN KEYSTONE ICU Project

The Keystone Initiative in Michigan utilized a checklist system to enhance patient safety in ICUs. Each participating hospital rolled out the checklist and observed the results with Peter Pronovost's supervision. Within three months, the infection rate in Michigan's ICUs dropped by 66%, saving more than 1,500 lives and reducing costs by roughly $175 million.¹²

SAFE SURGERY SAFE LIVES

To enhance patient safety and implement safer surgical procedures, a global research team led by Atul Gawande launched a project aimed at reducing adverse events in both operating rooms and wards. The team selected eight hospitals worldwide. This initiative reflects the importance of a global approach to patient safety, utilizing evidence-based practices and collaboration to improve outcomes in healthcare settings worldwide.⁹

🌐 NEWS!

2009

50%

A reduction in mortality was observed across the eight hospitals during the WHO's initial research.¹⁰

THE OFFICIAL CHECKLIST

After extensive research spanning several years, the World Health Organization developed a surgical safety checklist in 2009 that healthcare workers worldwide use in their operating rooms today. This standardized and universal checklist has become an essential tool for ensuring patient safety during surgical procedures, reflecting the WHO's commitment to improving healthcare outcomes globally.¹⁰

🇺🇸 NEWS!

2010

22%

A relative reduction in postoperative mortality was observed after the implementation of the Checklist in South Carolina.¹⁰

🏴󠁧󠁢󠁳󠁣󠁴󠁿 NEWS!

2019

36%

A reduction in post-surgical deaths was observed since the introduction of the Checklist in Scotland.¹⁰

🇮🇷 NEWS!

2011

57%

A reduction in surgical complications was observed in a 374-bed hospital after using the Checklist in Iran.¹⁰

WORLDWIDE IMPACT

As of 2019, the WHO's checklist is utilized in 70% of operating rooms worldwide, with over 20 countries adopting it as their national standard.¹⁰

From Past Milestones to Future Innovations

The Post-Implementation Boom in Research

The academic research on surgical checklists has surged significantly since the World Health Organization (WHO) endorsed its own checklist. Surgeons and researchers consistently unveil new insights to enhance patient safety, operating room efficiency, and team communication with the goal of improving patient safety in any hospital, regardless of size or budget.

The journey continues, and the Checklist has become a fundamental aspect of safety protocols in surgery, ensuring that patient safety remains a top priority and pushing for safer and more efficient healthcare practices globally.

DECREASEs infections

In 2021, a study in Brazil concluded that the implementation of the surgical checklist in 2010 reduced surgical site infections (SSI), particularly in contaminated and infected wounds.³ According to their findings, the checklist also lowered infections caused by hard-to-treat microorganisms, decreased antimicrobial resistance, and led to a 3.2% drop in in-hospital mortality. The use of the checklist demonstrated a positive impact on patient safety and outcomes.

DECREASEs infections

In 2021, a study in Brazil concluded that the implementation of the surgical checklist in 2010 reduced surgical site infections (SSI), particularly in contaminated and infected wounds.³ According to their findings, the checklist also lowered infections caused by hard-to-treat microorganisms, decreased antimicrobial resistance, and led to a 3.2% drop in in-hospital mortality. The use of the checklist demonstrated a positive impact on patient safety and outcomes.

DECREASEs infections

In 2021, a study in Brazil concluded that the implementation of the surgical checklist in 2010 reduced surgical site infections (SSI), particularly in contaminated and infected wounds.³ According to their findings, the checklist also lowered infections caused by hard-to-treat microorganisms, decreased antimicrobial resistance, and led to a 3.2% drop in in-hospital mortality. The use of the checklist demonstrated a positive impact on patient safety and outcomes.

drops Morbidity Rates

In a 2012 comparative study at the Department of Surgery at the University of Connecticut, the checklist was introduced for high-risk procedures in three 60-minute team training sessions. With an impressive 97.26% completion rate, cases utilizing the checklist saw a substantial drop in 30-day morbidity, decreasing from 23.60% to 8.20% compared to historical controls. This study underscored that the integration of a comprehensive checklist, alongside team training, profoundly enhances patient outcomes, presenting a feasible and impactful strategy for elevating surgical safety.¹

drops Morbidity Rates

In a 2012 comparative study at the Department of Surgery at the University of Connecticut, the checklist was introduced for high-risk procedures in three 60-minute team training sessions. With an impressive 97.26% completion rate, cases utilizing the checklist saw a substantial drop in 30-day morbidity, decreasing from 23.60% to 8.20% compared to historical controls. This study underscored that the integration of a comprehensive checklist, alongside team training, profoundly enhances patient outcomes, presenting a feasible and impactful strategy for elevating surgical safety.¹

drops Morbidity Rates

In a 2012 comparative study at the Department of Surgery at the University of Connecticut, the checklist was introduced for high-risk procedures in three 60-minute team training sessions. With an impressive 97.26% completion rate, cases utilizing the checklist saw a substantial drop in 30-day morbidity, decreasing from 23.60% to 8.20% compared to historical controls. This study underscored that the integration of a comprehensive checklist, alongside team training, profoundly enhances patient outcomes, presenting a feasible and impactful strategy for elevating surgical safety.¹

SHORTEns HOSPITAL STAYS

In 2015, a randomized controlled trial conducted in Norway revealed that the use of the WHO Surgical Safety Checklist (SSC) led to shorter hospital stays by almost a day on average. It significantly lowered complications during hospital stays, dropping from 19.9% to 11.5%. The checklist proved effective, reducing the chances of issues (hence shorter stays) even when considering other factors.⁶

SHORTEns HOSPITAL STAYS

In 2015, a randomized controlled trial conducted in Norway revealed that the use of the WHO Surgical Safety Checklist (SSC) led to shorter hospital stays by almost a day on average. It significantly lowered complications during hospital stays, dropping from 19.9% to 11.5%. The checklist proved effective, reducing the chances of issues (hence shorter stays) even when considering other factors.⁶

SHORTEns HOSPITAL STAYS

In 2015, a randomized controlled trial conducted in Norway revealed that the use of the WHO Surgical Safety Checklist (SSC) led to shorter hospital stays by almost a day on average. It significantly lowered complications during hospital stays, dropping from 19.9% to 11.5%. The checklist proved effective, reducing the chances of issues (hence shorter stays) even when considering other factors.⁶

IMPROVEs teamwork

In 2023, a qualitative study conducted in Switzerland revealed positive impacts on leadership, teamwork, timing, and acceptance with the use of the WHO Surgical Safety Checklist. Challenges, including understanding and training gaps, resulted in execution variations despite effective implementation. Improvement in teamwork and communication occurred, but hurdles influenced overall effectiveness.¹³

IMPROVEs teamwork

In 2023, a qualitative study conducted in Switzerland revealed positive impacts on leadership, teamwork, timing, and acceptance with the use of the WHO Surgical Safety Checklist. Challenges, including understanding and training gaps, resulted in execution variations despite effective implementation. Improvement in teamwork and communication occurred, but hurdles influenced overall effectiveness.¹³

IMPROVEs teamwork

In 2023, a qualitative study conducted in Switzerland revealed positive impacts on leadership, teamwork, timing, and acceptance with the use of the WHO Surgical Safety Checklist. Challenges, including understanding and training gaps, resulted in execution variations despite effective implementation. Improvement in teamwork and communication occurred, but hurdles influenced overall effectiveness.¹³

ENHANCEs SAFETY CULTURE

In 2012, a 20-study review conducted in Germany underscored the powerful impact of the Surgical Safety Checklist, revealing up to a 62% reduction in perioperative mortality and a 37% drop in morbidity. The study concluded that the checklist serves as a crucial instrument for enhancing communication, teamwork, and safety culture in the operating room.⁴

ENHANCEs SAFETY CULTURE

In 2012, a 20-study review conducted in Germany underscored the powerful impact of the Surgical Safety Checklist, revealing up to a 62% reduction in perioperative mortality and a 37% drop in morbidity. The study concluded that the checklist serves as a crucial instrument for enhancing communication, teamwork, and safety culture in the operating room.⁴

ENHANCEs SAFETY CULTURE

In 2012, a 20-study review conducted in Germany underscored the powerful impact of the Surgical Safety Checklist, revealing up to a 62% reduction in perioperative mortality and a 37% drop in morbidity. The study concluded that the checklist serves as a crucial instrument for enhancing communication, teamwork, and safety culture in the operating room.⁴

Adapts to various surgical contexts

In a 2015 study conducted in India involving 700 surgery patients, those using a modified WHO Surgical Safety Checklist (Rc Arm) demonstrated significant improvements, with lower rates of complications such as wounds, abdominal issues, and bleeding. The study emphasized that the surgical safety checklist is not a rigid manual but a dynamic aid, adapting to various surgical contexts to enhance patient safety.²

Adapts to various surgical contexts

In a 2015 study conducted in India involving 700 surgery patients, those using a modified WHO Surgical Safety Checklist (Rc Arm) demonstrated significant improvements, with lower rates of complications such as wounds, abdominal issues, and bleeding. The study emphasized that the surgical safety checklist is not a rigid manual but a dynamic aid, adapting to various surgical contexts to enhance patient safety.²

Adapts to various surgical contexts

In a 2015 study conducted in India involving 700 surgery patients, those using a modified WHO Surgical Safety Checklist (Rc Arm) demonstrated significant improvements, with lower rates of complications such as wounds, abdominal issues, and bleeding. The study emphasized that the surgical safety checklist is not a rigid manual but a dynamic aid, adapting to various surgical contexts to enhance patient safety.²

Checklists in
Other Industries

Checklists In
Other Industries

Checklists In
Other Industries

-aviation-

The Miracle on the Hudson

In 2009, US Airways Flight 1549 struck a flock of geese after take-off, resulting in a complete loss of engine power. Captain Sullenberger and First Officer Skiles skillfully landed the plane in the Hudson River, ensuring the survival of all 155 people on board. The pilots' adherence to checklists, communication, and mutual support played a critical role, highlighting the significance of discipline and teamwork in aviation safety.⁵

-aerospace-

The Fourth Crew Member

Checklists played a crucial role in the Apollo 11 mission. From operating onboard computers to spacesuit procedures, every corner of the Apollo environment had a checklist. Even outside the spacecraft, astronauts relied heavily on checklists, with cuff checklists attached to their wrists. These checklists were so significant that Michael Collins referred to them as "The Fourth Crew Member," highlighting their importance in the mission's success.⁷

-CONSTRUCTION-

A Deadly Dance Night

In 1981, during a dance event at the Hyatt Regency Hotel in Kansas City, two suspended walkways collapsed, resulting in 114 fatalities and 216 injuries. The accident was caused by last-minute engineering changes, approved without thorough review and calculations. This event underscored the importance of effective communication, documentation, and checklists in preventing accidents.⁸

-nUCLEAR-

The Worst Nuclear Disaster

In 1986, the Chernobyl disaster resulted from a reactor shutdown gone wrong, leading to explosions, fires, and the release of radioactive materials. The accident exposed a weak safety culture, a lack of communication among stakeholders, coupled with strict hierarchies. The implementation of a checklist might have clarified procedures and ensured that key safety protocols were followed during routine operations and emergencies.¹¹

Checklists In
Other Industries

-aviation-

The Miracle on the Hudson

In 2009, US Airways Flight 1549 struck a flock of geese after take-off, resulting in a complete loss of engine power. Captain Sullenberger and First Officer Skiles skillfully landed the plane in the Hudson River, ensuring the survival of all 155 people on board. The pilots' adherence to checklists, communication, and mutual support played a critical role, highlighting the significance of discipline and teamwork in aviation safety.⁵

-aerospace-

The Fourth Crew Member

Checklists played a crucial role in the Apollo 11 mission. From operating onboard computers to spacesuit procedures, every corner of the Apollo environment had a checklist. Even outside the spacecraft, astronauts relied heavily on checklists, with cuff checklists attached to their wrists. These checklists were so significant that Michael Collins referred to them as "The Fourth Crew Member," highlighting their importance in the mission's success.⁷

-CONSTRUCTION-

A Deadly Dance Night

In 1981, during a dance event at the Hyatt Regency Hotel in Kansas City, two suspended walkways collapsed, resulting in 114 fatalities and 216 injuries. The accident was caused by last-minute engineering changes, approved without thorough review and calculations. This event underscored the importance of effective communication, documentation, and checklists in preventing accidents.⁸

-nUCLEAR-

The Worst Nuclear Disaster

In 1986, the Chernobyl disaster resulted from a reactor shutdown gone wrong, leading to explosions, fires, and the release of radioactive materials. The accident exposed a weak safety culture, a lack of communication among stakeholders, coupled with strict hierarchies. The implementation of a checklist might have clarified procedures and ensured that key safety protocols were followed during routine operations and emergencies.¹¹

Culture Challenges

In the operating room, advocates of checklists encounter resistance to change, lack of prioritization, poor team communication, and deep-rooted hierarchical structures, all of which can significantly diminish the efficacy of checklists.

The OR Black Box® solution

The OR Black Box® solution

The OR Black Box® solution

The OR Black Box facilitates team communication by enabling practitioners to assess their team's performance within a non-punitive environment. Fostering a culture of open communication and feedback can promote buy-in and acceptance.

The OR Black Box facilitates team communication by enabling practitioners to assess their team's performance within a non-punitive environment. Fostering a culture of open communication and feedback can promote buy-in and acceptance.

The OR Black Box facilitates team communication by enabling practitioners to assess their team's performance within a non-punitive environment. Fostering a culture of open communication and feedback can promote buy-in and acceptance.

Efficiency Challenges

Checklists can inadvertently introduce efficiency hurdles. The additional workload associated with them must be managed effectively to prevent employee burnout and maintain a balance between high-quality care delivery and efficiency.

The OR Black Box® solution

The OR Black Box® solution

The OR Black Box® solution

The OR Black Box optimizes workflow by customizing checklists to meet the specific needs of each hospital. It regularly monitors their efficacy without imposing additional workload on hospital staff.

The OR Black Box optimizes workflow by customizing checklists to meet the specific needs of each hospital. It regularly monitors their efficacy without imposing additional workload on hospital staff.

The OR Black Box optimizes workflow by customizing checklists to meet the specific needs of each hospital. It regularly monitors their efficacy without imposing additional workload on hospital staff.

Execution Challenges

Insufficient training, lack of ownership, and unclear expectations lead to shortcuts and a checkbox mentality, rather than fostering a shared, collaborative mental model of the procedure. This undermines the effectiveness and purpose of the checklist.

The OR Black Box® Solution

The OR Black Box® Solution

The OR Black Box® Solution

The OR Black Box implements a checklist adaptable to diverse settings, following universal standards. This approach ensures that clear expectations for improvement are known and measured, promoting the use of checklists as collaborative tools.

The OR Black Box implements a checklist adaptable to diverse settings, following universal standards. This approach ensures that clear expectations for improvement are known and measured, promoting the use of checklists as collaborative tools.

The OR Black Box implements a checklist adaptable to diverse settings, following universal standards. This approach ensures that clear expectations for improvement are known and measured, promoting the use of checklists as collaborative tools.

Measurement Challenges

Maintaining quality and compliance standards presents a challenge when audits are infrequent, poorly executed, short-lived, and reluctant to incorporate feedback aimed at enhancing the checklist's execution.

The OR Black Box® solution

The OR Black Box® solution

The OR Black Box® solution

The OR Black Box conducts regular audits to assess its adherence and effectiveness, serving as a centralized hub. It establishes a clear communication channel and feedback mechanism to address measurement and scalability challenges as they arise.

The OR Black Box conducts regular audits to assess its adherence and effectiveness, serving as a centralized hub. It establishes a clear communication channel and feedback mechanism to address measurement and scalability challenges as they arise.

The OR Black Box conducts regular audits to assess its adherence and effectiveness, serving as a centralized hub. It establishes a clear communication channel and feedback mechanism to address measurement and scalability challenges as they arise.

Checklists are not a cure-all solution

Checklists are invaluable across diverse sectors such as aviation, medicine, and engineering, facilitating adherence to critical steps and efficient communication. However, the efficacy of a checklist hinges on its design, implementation, and the specific operational context.

Ultimately, the goal of a checklist goes beyond strict compliance; it aims to align the team and foster a culture of collaboration. It is the responsibility of organizations and hospitals to promote meticulous teamwork by effectively utilizing checklists.

There is a solution for safer surgery

There is a solution for safer surgery

There is a solution for safer surgery

Learn more about the OR Black Box®

Learn more about
the OR Black Box®

Learn more about the OR Black Box®

References

References

References

¹ Bliss, L. A., Ross-Richardson, C. B., Sanzari, L. J., Shapiro, D. S., Lukianoff, A. E., Bernstein, B. A., & Ellner, S. J. (2012). Thirty-day outcomes support implementation of a surgical safety checklist. Journal of the American College of Surgeons, 215(6), 766–776. https://doi.org/10.1016/j.jamcollsurg.2012.07.015 
² Chaudhary, N., Varma, V., Kapoor, S., Mehta, N., Kumaran, V., & Nundy, S. (2015). Implementation of a surgical safety checklist and postoperative outcomes: a prospective randomized controlled study. Journal of gastrointestinal surgery : official journal of the Society for Surgery of the Alimentary Tract, 19(5), 935–942. https://doi.org/10.1007/s11605-015-2772-9
³ de Almeida, S. M., de Menezes, F. G., Martino, M. D. V., Tachira, C. R., Toniolo, A. D. R., Fukumoto, H. L., Edmond, M. B., & Marra, A. R. (2021). Impact of a surgical safety checklist on surgical site infections, antimicrobial resistance, antimicrobial consumption, costs and mortality. The Journal of hospital infection, 116, 10–15. https://doi.org/10.1016/j.jhin.2021.05.003
 ⁴ Fudickar, A., Hörle, K., Wiltfang, J., & Bein, B. (2012). The effect of the WHO Surgical Safety Checklist on complication rate and communication. Deutsches Arzteblatt international, 109(42), 695–701. https://doi.org/10.3238/arztebl.2012.0695
⁵ Gawande, A. (2010). The Checklist Manifesto. : Profile Books LTD.
⁶ Haugen, A., Søfteland, E., Almeland, S., Sevdalis, N., Vonen, B., Eide, G., Nortvedt, M., Harthug, S. Effect of the World Health Organization Checklist on Patient Outcomes: A Stepped Wedge Cluster Randomized Controlled Trial. Annals of Surgery 261(5):p 821-828, May 2015. | DOI: 10.1097/SLA.0000000000000716
⁷ Hersch, M. (2009, July 19). The Fourth Crewmember. Smithsonian Magazine. https://www.smithsonianmag.com/air-space-magazine/the-fourth-crewmember-37046329/ 
⁸ Hyatt Regency Walkway Collapse. (n.d.). Online Ethics Center. https://onlineethics.org/print/pdf/node/44241
⁹ Kirby, T. (2010, September 25). Atul Gawande—making surgery safer worldwide [Editorial]. Perspectives, 376(9746), 1045. https://doi.org/https://doi.org/10.1016/S0140-6736(10)61473-0
¹⁰ Lifebox, Ariadne Labs. (2020, January 15). Checking In On the Checklist. Lifebox. Retrieved February 27, 2024, from https://www.lifebox.org/checkinginonthechecklist/ 
¹¹ Moller, N., Hansson, S., Holmberg, J., Rollenhagen, C. (Eds.). (2017). Handbook of Safety Principles. : John Wiley & Sons Inc.. https://doi.org/10.1002/9781119443070.ch28
¹² Reason J. (2000). Human error: models and management. BMJ (Clinical research ed.), 320(7237), 768–770. https://doi.org/10.1136/bmj.320.7237.768
¹³ Wyss, M., Kolbe, M., & Grande, B. (2023). Make a difference: implementation, quality and effectiveness of the WHO Surgical Safety Checklist-a narrative review. Journal of thoracic disease, 15(10), 5723–5735. https://doi.org/10.21037/jtd-22-1807