WHO Surgical Safety Checklist: Research-Backed Efficacy, Real-World Neglect

In today's fast-paced healthcare environment, ensuring patient safety during surgical procedures is paramount. With the rise of medical advancements and complex surgeries, associated risks have become more apparent, necessitating a structured approach to safety. Addressing these challenges, the World Health Organization (WHO)¹ introduced the Surgical Safety Checklist² in 2008.

This initiative is a critical step towards minimizing surgical risks and enhancing outcomes for patients globally. The checklist better equips healthcare practitioners to standardize procedures, foster effective communication, and promote a culture of safety in operating rooms worldwide.

In this article, we will discuss:

• The history of the surgical safety checklist

• The benefits of using the surgical safety checklist

• The reality of surgical safety checklist compliance

• How to improve surgical safety checklist compliance and adherence using the OR Black Box

The History of the Surgical Safety Checklist

Surgical interventions aim to preserve and improve lives, but when performed without adequate safety measures, they can lead to significant patient harm. According to the WHO: 

• the reported crude mortality rate after major surgery is 0.5-5% 

• complications after inpatient operations occur in up to 25% of patients 

• in industrialized countries, nearly half of all adverse events in hospitalized patients are related to surgical care 

• at least half of the cases in which surgery led to harm are considered preventable  

In 2008, the WHO introduced the Surgical Safety Checklist, a simple, yet powerful tool designed to improve patient safety in operating rooms worldwide. The WHO Surgical Safety Checklist is a 19-item tool divided into three critical phases of surgical care: 

1. Before induction of anesthesia ("Sign In") 

2. Before skin incision ("Time Out") 

3. Before the patient leaves the operating room ("Sign Out")  

The checklist aims to reduce surgical complications and mortality by promoting teamwork, communication, and consistency in perioperative care and has become an essential tool for ensuring patient safety during surgical procedures.  

Benefits of Using the Surgical Safety Checklist 

As of 2019, the WHO's checklist is utilized in 70% of operating rooms worldwide,³ with over 20 countries adopting it as their national standard. The importance of the checklist cannot be overstated. Institutions worldwide have seen numerous benefits after introducing the checklist.  

•  A decrease in surgical infections: In 2021, a study in Brazil⁴ concluded that the implementation of the 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. 

• A drop in morbidity rates: In a 2012 comparative study at the Department of Surgery at the University of Connecticut,⁵ 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. 

• Shortened hospital stays: In 2015, a randomized controlled trial conducted in Norway⁶ revealed that the use of the checklist 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%. 

• An improvement in safety culture: In 2012, a 20-study review conducted in Germany⁷ underscored the powerful impact of the checklist, revealing up to a 62% reduction in perioperative mortality and a 37% drop in morbidity.  

The Reality of Surgical Safety Checklist Compliance 

While the benefits of the Surgical Safety Checklist are clear, research shows that complete adherence to all items is surprisingly inconsistent. Findings across Colorado hospitals in 2015⁸ indicated that only 71% of observers reported active participation by physicians in the checklist; 9% reported that "the majority did not pay attention" and 4% reported that the team was "just going through the motions". There were also significant differences among surgical specialty groups in most elements.  

Furthermore, a 2021 Annals of Surgery study⁹ that surveyed surgical teams’ attitudes about the checklist found that only 50.3% of respondents were satisfied their team’s use of the checklist, and only 47.5% reported team members stopping to fully participate in the process.  

These low compliance rates can be attributed to various issues, including: 

• Culture challenges: In the OR, 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. 

• 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. 

• 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. 

• 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.  

Improving Surgical Safety Checklist Compliance and Adherence 

Surgical Safety Technologies’ OR Black Box®¹⁰ platform leverages advanced data analytics, video capabilities, artificial intelligence, and machine learning to elevate patient safety, optimize operations, and facilitate continuous improvement in the OR. Cutting-edge technologies enable protocol auditing, real-time operational analytics, autonomous risk detection, and predictive insights to empower clinicians with the intelligence to achieve superior outcomes.  

Through leveraging the OR Black Box, organizations can recognize the following benefits with their surgical safety checklist initiatives: 

• Enhance compliance through objective data collection: Video recording in the OR provides an unbiased method to assess surgical safety checklist compliance. Unlike traditional auditing methods that may influence behavior due to the presence of a live auditor, the OR Black Box captures objective data on checklist adherence. This approach allows for a more accurate representation of day-to-day practices, potentially identifying areas for improvement in safety protocols and checklist procedures. The resulting insights can lead to more consistent and thorough implementation of safety measures, potentially reducing errors and improving patient outcomes.

• Foster a supportive culture: The OR Black Box facilitates communication by enabling practitioners to assess their team's performance within a non-punitive environment. It also helps identify and address instances of toxic behavior or bullying, particularly from team members with greater perceived authority. The use of objective evidence of interactions promotes accountability across all levels of the surgical team. Fostering a culture of open communication, mutual respect, and psychological safety empowers all team members to speak up about safety concerns regardless of their position. This inclusive approach can enhance team cohesion, improve checklist compliance, and ultimately lead to better patient outcomes. 

• Create more efficiencies: 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. 

• Improve checklist execution: 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. 

• Support measurement: The OR Black Box provides regular audits to assess the team’s adherence and effectiveness. It supports the establishment of a clear communication channel and feedback mechanism to address measurement and scalability challenges as they arise.  

The Surgical Safety Checklist is a proven tool for improving patient outcomes and helping to make surgery safer. However, its success relies on effective implementation, consistency in use, and ongoing auditing initiatives.   

It is the responsibility of all OR team members to strive to use this valuable resource to its full potential, recognizing that each item on the checklist represents an opportunity to prevent harm and save lives. By fostering a culture of safety, open communication, and continuous improvement, healthcare organizations can work toward a future where 100% checklist compliance is not just an aspiration, but a reality in ORs worldwide.  

If your organization is interested in learning more about how to leverage the OR Black Box in Surgical Safety Checklist initiatives,¹¹ contact us.  

Recommended Reading

1. World Health Organization. (2019). Safe Surgery. Www.who.int; World Health Organisation. https://www.who.int/teams/integrated-health-services/patient-safety/research/safe-surgery 

2. Surgical Safety Technologies. (2024). The Surgical Safety Checklist. https://www.checklist.surgicalsafety.com/ Accessed September 18, 2024. 

3. Checking In On the Checklist at 10 Years. (n.d.). Lifebox. Retrieved July 16, 2024, from https://www.lifebox.org/checkinginonthechecklist/  

4. de Almeida, S. M., de Menezes, F. G., Martino, M. D. V., Tachira, C. R., Toniolo, A. do R., Fukumoto, H. L., Edmond, M. B., & Marra, A. R. (2021, May 15). Impact of a surgical safety checklist on surgical site infections, antimicrobial resistance, antimicrobial consumption, costs and mortality. The Journal of Hospital Infection. https://doi.org/10.1016/j.jhin.2021.05.003  

5. 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  ‌

6. Haugen, A. S., Søfteland, E., Almeland, S. K., Sevdalis, N., Vonen, B., Eide, G. E., Nortvedt, M. W., & Harthug, S. (2015). Effect of the World Health Organization Checklist on Patient Outcomes. Annals of Surgery, 261(5), 821–828. https://doi.org/10.1097/sla.0000000000000716  

7. Ärzteblatt, D. Ä. G., Redaktion Deutsches. (n.d.). The Effect of the WHO Surgical Safety Checklist on Complication Rate and Communication (19.10.2012). Deutsches Ärzteblatt. https://www.aerzteblatt.de/int/archive/article/131757  ‌

8. Biffl, W. L., Gallagher, A. W., Pieracci, F. M., & Berumen, C. (2015). Suboptimal compliance with surgical safety checklists in Colorado: A prospective observational study reveals differences between surgical specialties. Patient Safety in Surgery, 9(1), 5. https://doi.org/10.1186/s13037-014-0056-z  

9. Urban, D., Burian, B. K., Patel, K., Turley, N. W., Elam, M., MacRobie, A. G., Merry, A. F., Kumar, M., Hannenberg, A., Haynes, A. B., & Brindle, M. E. (2021). Surgical Teams’ Attitudes About Surgical Safety and the Surgical Safety Checklist at 10 Years. Annals of Surgery Open, 2(3), e075. https://doi.org/10.1097/as9.0000000000000075   

10. Surgical Safety Technologies. (2024). Revolutionize Surgical Decision-Making with the Power of AI. https://www.surgicalsafety.com/platform/or-black-box Accessed September 18, 2024. 

11. Surgical Safety Technologies. (2024). Surgical Safety Checklist Module. https://www.surgicalsafety.com/data-sheets/surgical-safety-checklist-module Accessed September 18, 2024.