SYSTEMATIC REVIEW Surgical checklists: a systematic review ... · briefing, checklist, checkout, communication, docu- ... De Vries et al7 tested the 90-item SURPASS check-list. In

Surgical checklists: a systematicreview of impacts andimplementation

Jonathan R Treadwell, Scott Lucas, Amy Y Tsou

▸ Additional material ispublished online only. To viewplease visit the journal online(http://dx.doi.org/10.1136/bmjqs-2012-001797)

ECRI Institute, PlymouthMeeting, Pennsylvania, USA

Correspondence toDr Jonathan R Treadwell,ECRI Institute, 5200 ButlerPike, Plymouth Meeting,PA 19462-1298, USA;[email protected]

Received 31 December 2012Accepted 12 July 2013Published Online First6 August 2013

To cite: Treadwell JR,Lucas S, Tsou AY. BMJ QualSaf 2014;23:299–318.

ABSTRACTBackground Surgical complications represent asignificant cause of morbidity and mortality withthe rate of major complications after inpatientsurgery estimated at 3–17% in industrialisedcountries. The purpose of this review was tosummarise experience with surgical checklist useand efficacy for improving patient safety.Methods A search of four databases (MEDLINE,CINAHL, EMBASE and the Cochrane Database ofControlled Trials) was conducted from 1 January2000 to 26 October 2012. Articles describingactual use of the WHO checklist, the SurgicalPatient Safety System (SURPASS) checklist, awrong-site surgery checklist or an anaesthesiaequipment checklist were eligible for inclusion(this manuscript summarises all but theanaesthesia equipment checklists, which aredescribed in the Agency for Healthcare Researchand Quality publication).Results We included a total of 33 studies. Wereport a variety of outcomes including avoidanceof adverse events, facilitators and barriers toimplementation. Checklists have been adopted ina wide variety of settings and represent apromising strategy for improving the culture ofpatient safety and perioperative care in a widevariety of settings. Surgical checklists wereassociated with increased detection of potentialsafety hazards, decreased surgical complicationsand improved communication among operatingstaff. Strategies for successful checklistimplementation included enlisting institutionalleaders as local champions, incorporating stafffeedback for checklist adaptation and avoidingredundancies with existing systems for collectinginformation.Conclusions Surgical checklists represent arelatively simple and promising strategy foraddressing surgical patient safety worldwide.Further studies are needed to evaluate to whatdegree checklists improve clinical outcomes andwhether improvements may be morepronounced in particular settings.

THE PROBLEMAlthough surgery represents a mainstay ofmedical treatment, in industrialised coun-tries, the rate of perioperative death dir-ectly due to inpatient surgery has beenestimated at 0.4–0.8%, and the rate ofmajor complications has been estimated at3–17%.1 2 These complications includewrong patient/procedure/site surgery,anaesthesia equipment problems, lack ofavailability of necessary equipment,unanticipated blood loss, non-sterileequipment, and surgical items (eg,sponges) left inside patients. The com-plexity of most surgical proceduresrequires a well coordinated team toprevent these events.

STRATEGIES FOR PATIENT SAFETYSurgical checklists can potentially preventerrors and complications which mayoccur during surgery or perioperatively.A variety of interventions have shownpromise for improving patient safety. Forinstance, Neily et al3 found that surgicalteam training which incorporated surgicalchecklists along with communicationstrategies was associated with a significantreduction in surgical mortality. Arriagaet al4 found that checklists dramaticallyimproved adherence to critical processesof care in simulated scenarios of surgicalcrises. Studies have suggested that check-lists may reduce errors for many reasons,including ensuring that all critical tasksare carried out, encouraging a non-hierarchical team-based approach, enhan-cing communication, catching nearmisses early, anticipating potential com-plications, and having technologies tomanage anticipated and unanticipatedcomplications. The WHO Surgical SafetyChecklist is a prominent example of asurgical checklist intended to ensure safe

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surgery and minimise complications. Launched inJune 2008, it has been translated into at least six lan-guages.5 The 2009 WHO checklist (http://www.who.int/patientsafety/safesurgery/en/) contains 22 items inthree phases:▸ Before induction of anaesthesia, covering areas such as

patient identification, anaesthesia equipment check and apulse oximetry check.

▸ Before skin incision, covering areas such as team intro-ductions, review of critical steps and antibioticprophylaxis.

▸ Before patient leaves operating room (OR), coveringareas such as checking counts of instruments, specimenlabelling and concerns for recovery.In this paper we discuss the evidence for three

patient safety efforts associated with surgical check-lists. The WHO Surgical Safety Checklist and theJoint Commission Universal Protocol (UP) forPreventing Wrong Site, Wrong Procedure, WrongPerson Surgery6 have each been widely implementedto improve care when surgical procedures are per-formed. We also discuss the Surgical Patient SafetySystem (SURPASS) checklist,7–10 which represents amore comprehensive approach, capturing clinical carefrom admission to surgery to discharge.

REVIEW STRATEGYWe conducted a systematic literature search ofMEDLINE, CINAHL, EMBASE and the CochraneDatabase of Controlled Trials using a search strategydeveloped by a medical librarian. The search strategy(available upon request) included studies publishedfrom 1 January 2000 to 26 October 2012, and used acombination of medical subject headings and key-words related to checklists (‘anaesthesia checklist’,briefing, checklist, checkout, communication, docu-mentation, instrument, ‘safety checklist’, tool, ‘surgicalchecklist’, protocol, ‘WHO checklist’).Given the limited scope of this review, we focused

on any articles describing actual use of the WHO

checklist, the SURPASS checklist, a wrong-site surgerychecklist or anaesthesia equipment checklists. We rec-ognise other surgical checklists exist; however, manyof these have only been implemented at a single insti-tution. We also included articles describing use ofanaesthesia checklists to detect equipment failure insimulated scenarios. This manuscript summarises allbut the anaesthesia equipment checklists, which aredescribed in an Agency for Healthcare Research andQuality (AHRQ) publication.11 An overview of thethree types of checklists discussed in this paper isgiven in table 1. We included a total of 33 studies ofthese checklists and tabulated the reported outcomes,facilitators and barriers to checklist implementation.

BENEFITS AND HARMSBenefitsWHO checklistThe 2008 WHO Surgical Safety Checklist was testedat eight sites around the world.5 These settings variedgreatly in the number of beds (range 371–1800), thenumber of ORs (range 3–39), and the income level ofthe country (four low, four high). Surgical safety pol-icies prior to implementation of the WHO Checklistalso differed regarding the use of routine intraopera-tive monitoring with pulse oximetry (six of eightsites), oral confirmation of patients’ identity and surgi-cal site in the OR (only two of eight sites), androutine administration of prophylactic antibiotics inthe OR (five of eight sites). None of the eight siteshad a ‘standard plan for intravenous access for casesof high blood loss’, or formal team briefings preopera-tively or postoperatively.Baseline data were obtained at each site for

3 months prior to checklist introduction, involving atotal of 3733 surgical procedures. In the subsequent3–6-month period after checklist introduction, involv-ing 3955 procedures, data showed decreases in patientmortality (from 1.5% to 0.8%) and inpatient compli-cations (from 11% to 7%). No single site was driving

Table 1 Overview of the three checklists

Checklist Clinical scope Staff involvement Categories and numbers of items

WHO SurgicalSafety Checklist

Surgical care Surgeon(s), anaesthetist(s),nurse(s)

Total of 22 items, in three categories:▸ Before induction of anaesthesia

(7 items)▸ Before skin incision (10 items)▸ Before patient leaves operating

room (5 items)SURPASS All surgical care between patient admission and

dischargeWard doctor(s), surgeon(s),anaesthetist(s), nurse(s) oroperating assistant(s)

Total of 90 items, in 11 categories

Checklists based onthe UniversalProtocol

Surgical care, but also (if applicable) when theprocedure is scheduled, when the patient enters thehealthcare facility, and anytime care is transferredbetween caregivers

Varies by site Varies by site

SURPASS, Surgical Patient Safety System.

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the findings, as evidenced by the persistence of find-ings after the removal of any single site in a sensitivityanalysis. The authors found that the performancerates for six specific safety indicators (eg, using apulse oximeter) also increased after checklist introduc-tion, suggesting that the safety indicators may havebeen responsible for the lower rates.In discussing the results, the authors acknowledged

that the underlying explanations were ‘most likelymultifactorial’ and included the following:▸ The checklist itself.▸ A Hawthorne effect (ie, rates may have decreased

because OR personnel knew they were being measured).The authors argued against this possibility based on twoaspects of their data: this knowledge was in place beforeand after checklist introduction, and the subset of proce-dures for which study personnel were present in the ORhad the same reductions in complications as procedureswhen study personnel were absent from the OR.

▸ The simple existence of a formal pause or preoperativebriefing (which could be done without a ‘checklist’).Such a pause is a necessary component of the checklist.

▸ Increased uptake of safety technologies (eg, administer-ing antibiotics in the OR rather than in preoperativewards). This change could be considered a byproduct ofchecklist introduction (ie, hospitals made more antibio-tics directly available in the OR because of the presenceof an antibiotics-related item on the checklist).

▸ A broad change in safety culture and teamwork at thatsite, an explanation supported by the finding that greaterincreases in safety attitudes at the pilot sites were asso-ciated with greater reductions in complications.12

Subsequent publications about the WHO SurgicalSafety Checklist have found improvements in urgentsurgery13 and safety attitudes.12 14 Haynes et al12

reported that 80% of respondents considered thechecklist easy to use, 20% believed it took too longand 93% of respondents would want the checklistused if they were undergoing surgery. Likewise,Helmio and colleagues15 found that 76% of OR staffagreed the checklist improved safety, 68% agreed itimproved error prevention and 93% would want thechecklist used if they were having surgery. Teammembers reported high satisfaction and positivityabout the checklist, and estimated that it only tookabout 2 min to complete.16

SURPASS checklistThe WHO checklist focuses primarily on eventsoccurring within the OR. However, an estimated 53–70% of surgical errors occur outside the OR.8 17 18

The SURPASS checklist7–10 attempts to address theseerrors by encompassing all care between patientadmission and discharge. Within the OR itself, theSURPASS checklist is less specific than the WHOchecklist (eg, the SURPASS checklist does not specific-ally mention any of the following: pulse oximetry, dif-ficult airway, risk of blood loss (although it asks

whether blood products are available), team introduc-tions, and anticipation of critical events).De Vries et al7 tested the 90-item SURPASS check-

list. In six test hospitals, the 3-month period after thechecklist was initiated (compared with the 3 monthsbefore) saw numerous improvements: decreases in thepercentage of patients with complications, in-hospitalmortality, patient temporary disability and reopera-tions. No such improvements were found among thefive control hospitals. Interestingly, the degree ofimprovement was associated with greater compliancewith the checklist, providing greater confidence thatthe checklist itself was responsible for improvements.A subsequent retrospective review of 294 medicalclaims10 estimated that 40% of deaths and 29% ofliability incidents might have been prevented if theSURPASS checklist had been used. Further review of6313 checklists performed found that 41% detectedat least one oversight, with the most common occur-ring postoperatively (lack of postoperative instructionsconcerning ventilation by the anaesthesiologist andmissing medication prescriptions at discharge).19

Wrong-site surgery checklistsIn January 2004, the Joint Commission launched thefirst version of the UP for Preventing Wrong Site,Wrong Procedure, Wrong Person Surgery.6 20

Preoperative verifications of person, procedure andsite are supposed to occur in the OR and (if applic-able) when the procedure is scheduled, when thepatient enters the healthcare facility, and anytime careis transferred between caregivers. Site marking shouldinvolve only the operative site and should be visiblebefore the patient is draped. The ‘time out’ is to occurbefore incision and involve the entire OR team. TheUP is not a checklist21 but could be implementedusing one or more checklists. Steps 1 and 3 specific-ally mention the potential use of a checklist.Wrong-site surgery is rare; estimates for various pro-

cedures range from 1 in 13 000 procedures forwrong-site anaesthesia block to 1 in 4200 for wrong-side ureteral stents.22 A general systematic review esti-mated that the overall rate was 1–5 per 10 000 proce-dures.23 Given the rarity, demonstrating a statisticalreduction would require an unfeasibly large study. Asystematic review searched for literature and con-cluded there was ‘no literature to substantiate theeffectiveness of the current Joint CommissionUniversal Protocol in decreasing the rate of wrongsite, wrong level surgery.’23 Therefore, the preventivebenefits of a checklist to prevent wrong-site surgeryare generally assumed based on clinical expertise.

HARMSDirect harms of surgical checklists have not beenreported. In 2011, Sewell et al24 reported that afterWHO implementation, the rate of lower respiratorytract infections actually increased from 2.1% to 2.5%.

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Whether this increase was caused by the checklist isunclear; however the authors attributed rate reduc-tions to the checklist, so they could also have attribu-ted rate increases to the checklist. Despite the absenceof reported direct harms, some checklist users haveexpressed concern regarding potential harms. Forinstance, some worry that checklist use decreases ORefficiency or creates unnecessary patient anxiety. In2011, Kearns et al25 reported that 3 months afterWHO checklist implementation, 30% believed it wasan inconvenience in emergency cases; however, thispercentage was lower than it had been prior to imple-mentation of the checklist when staff were askedhypothetically whether they believed it would be aninconvenience in emergency cases (53% said it wouldbe). OR efficiency might also be compromised ifchecklists duplicated already existing safety proceduresor if nurses responsible for performing the checklistwere unfamiliar with its execution due to high staffingturnover. 26 27 In one study,27 staff expressed concernsthat prompting patients for their name several timesimmediately before induction of anaesthesia mightcreate unnecessary anxiety.

IMPLEMENTATION CONSIDERATIONS AND COSTSWHO checklistWe included 23 reports of WHO checklist implemen-tation. Twenty-one studies reported WHO checklistimplementation at other sites and two reportedexperience at institutions involved in the originalstudy (table 2).Results from the 23 implementation reports appear

in table 3. In keeping with WHO recommendations,checklists were tailored and implemented differentlyfor a wide variety of contexts. At present, it remainsunclear whether OR posters, paper tick boxes or elec-tronic medical records perform better. Feedback fromsurgical teams was generally positive, but supporttended to be greater from nurses and anaesthetiststhan from surgeons. For example, Vats et al26 foundthat anaesthetists and nurses were ‘largely supportive’but some surgeons were ‘not very enthusiastic’.Reasons cited for success included good training

and staff understanding, a local champion, supportfrom upper management, being able to modify thechecklist, distribution of responsibility, the feeling ofownership by team members, a stepwise implementa-tion process which incorporated real-time feedback,and enhanced communication and teamwork.Regarding communication, for example, Sewell et al24

found that 77% of users thought the checklistimproved team communication; this percentage was70% in the study by Kearns et al.25 The implementa-tion study by Conley et al28 emphasised that the localchampion should ‘persuasively explain why and adap-tively show how to use the checklist’. Styer et al29 andBohmer et al30 attributed success to recruiting seniorleaders of their institutions to be local champions and

incorporating real-time feedback into checklistprotocols.Barriers to implementation generally fell into four

categories: confusion regarding how to properly usethe checklist, pragmatic challenges to efficient work-flow, access to resources, and individual beliefs andattitudes. First, OR staff were sometimes confusedabout how to properly execute the checklist.15 27 31

For instance, Levy et al31 found significant confusionabout the timing of checklist items and who wasresponsible for prompting checklist questions amongOR staff. While inadequate education may play a part,Fourcade et al27 found that nurses were unfamiliarwith the checklist because of high staffing turnover.Vogts et al32 suggested that performance of ‘sign out’may be low since this section is not linked to a specificevent in patient management, unlike the ‘sign in’ and‘time out’ domains and thus lacks clarity.Second, checklist implementation occasionally

created pragmatic problems for OR workflow.Particular challenges include extra time,27 32 especiallyduring emergency procedures,33 and duplication ofsafety checks already routinely performed.26 27 In thestudy by Kearns et al25 30% felt that in emergencycases, the checklist was inconvenient. Third, develop-ing countries often lacked regular access to resources.Yuan et al14 reported that inconsistent access to anti-biotics and batteries hampered checklist use in twoLiberian hospitals. Likewise, Kasatpibal et al34

reported that surgical sites were not routinely markedbecause marking materials were unavailable in a Thaihospital. Finally, individual attitudes of staff towardsthe checklist played a major role in the outcome ofimplementation. Barriers included general surgeonresistance to changing habits, awkwardness of self-introductions and steep interpersonal hierarchy. Somenurses reported concerns about incurring legalresponsibility if a complication occurred after theysigned the checklist form.

Health outcomesIn terms of improved health outcomes (rightmostcolumns of table 3), 10 of the 21 implementationstudies reported relevant data. Among the 10 report-ing studies, however, reductions were generallyimpressive. For example, Askarian et al35 found thatsurgical complications decreased from 22.9% to 10%.Yuan et al14 reported that two Liberian hospitalsfound checklist introduction was significantly asso-ciated with fewer surgical site infections (adjusted OR(AOR) 0.28; 95% CI 0.15 to 0.54) and surgical com-plications (AOR 0.45; 95% CI 0.26 to 0.78).Similarly, the study at Royal Bolton36 found that

nine potential safety incidents were averted during a1-month period of checklist use. Other reportedimprovements appear in table 3.

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Table 2 Implementation studies of the WHO Surgical Safety checklist

Author [year]Description of Patient SafetyPractice (PSP) Study design Theory or logic model Description of organisation Safety context

Sewell et al[2011]24

2008 WHO surgical checklist,unmodified

Before and after study,comparing pre-trainingperiod to post-training

‘The underlying philosophy of thechecklist is that a true team approachwith good communication betweenoperating room team members is saferand more efficient than a hierarchicalsystem that relies on individuals’

A UK hospital, orthopaedic operations.28% of operations were urgent, and77% involved general anaesthesia

Pre-training period February–May 2009(480 operations). During this period: correctchecklist use was 8%, and 47% thought itimproved team communication; pre-trainingstaff perceptions: 55% thought it causedan unnecessary time delay, 28% thought itimproved patient safety, 47% thought itimproved team communication andteamwork, 64% would want the checklistused if they were having an operation

Helmio et al[2011]55

2008 WHO surgical checklist. Nospecialty-related changes, but some‘minor changes.’ Checklist included inpublication; modifications did notexclude any items

Before and after study ‘The idea of the checklist is to be anadd-on security tool for the defined safetystandard’

Finland, otorhinolaryngology head andneck surgery ORs. 747 operations in the2-month study periods combined. Allsubgroups of otorhinolaryngology headand neck surgery were included

One-month pre-implementation period inMay 2009 (304 operations): 17% wereurgent operations; 24% were on children;16% were local anaesthesia. Beforeimplementation: knowledge of OR-teams’names and roles ranged from 61% to92%. Discussing risks was 24%. Postopinstructions recorded 7–84%. Successfulcommunication 79–93%

Conley et al[2011]28

2008 WHO surgical checklist,unmodified

Case series None explicitly stated Five Washington State hospitals. Twohospitals had <10 ORs, one had 10–20and two had >20. Two urban, twosuburban and one rural

Nothing reported about pre-existing safetyculture. The Vice President for PatientSafety at the Washington State HospitalAssociation provided ‘significant assistance’.Checklist introduction December 2008 toJanuary 2009. Interviews conductedSeptember–December 2009. One of thefive hospitals had a recent wrong-siteincision that motivated surgical staff and‘opened people’s eyes to the need forongoing patient safety efforts’

Bell and Pontin[2010]56, Bell57

2008 WHO checklist adapted differentfor different surgical specialties. Checklistnot included in publication

Case series ‘Without a doubt, the checklist worksbest when all staff members are engaged’

Large two-hospital trust in the UK with10 000 staff and 850 000 patientsannually

Nothing about pre-existing safety culture.To prepare for the checklist, they set up aPatient Safety Working Group

Sparkes andRylah [2010]58

2008 WHO checklist locally adapted.Checklist included in publication;modifications did not exclude any items

Case series Discussed various ways a checklist couldenhance safety, including teamwork andeffective communication

Teaching hospital in the UK with 29ORs in five locations performingspecialised complex surgery

NR

Royal Bolton[2010]36

2008 WHO checklist, unmodified. Localadaptation of it was considered butultimately not done

Case series Improve patient safety by enhancingteamwork and communication

Trust in the UK with eight ORs Prior to the checklist, the trust already hada core group of patient safety expertsassembled; this group met to discuss howto introduce the checklist. They examinedthe previous year’s 41 safety incidents andall were ‘found to be avoidable had thechecklist been in use’

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Vats et al[2010]26

2008 WHO surgical checklist adapted forEngland and Wales. Checklist included inpublication; modifications did notexclude any items

Case series ‘the checklist ensures that critical tasksare carried out and that the team isadequately prepared for the operation’

UK academic hospital Nothing reported about pre-existing safetyculture. Piloted March–September 2008 ata London hospital in 58% of operations(424/729) among the two ORs selected(one for trauma/orthopaedics OR, the otherfor GI/GYN)

Kearns et al[2011]25

WHO surgical checklist, version NR.Some obstetric-specific checks had beenadded, but the list of revisions was notreported. Checklist not included inpublication

Before and after study ‘Checklists may be used to improvepatient safety by ensuring that allelements of a practice are instituted foreach new clinical event’

UK study in obstetrics ORs. Tertiaryreferral obstetric centre with ∼6400deliveries per year

Before introducing the checklist, theymeasured staff attitudes, preservingrespondent anonymity: 30% ‘felt familiar’with others in the OR, 81% feltcommunication could improve, 85% feltthat in elective cases the checklist would beuseful, 53% felt that in emergency casesthe checklist would be inconvenient

Norton andRangel [2010]59

2008 WHO checklist modified forpaediatric operations and also to meetthe 2009 Joint Commission UniversalProtocol. Checklist included inpublication. Removed the following threeitems from the WHO checklist: pulseoximetry, difficult airway, anticipatedblood loss

Case series Checklist can help to reduce breakdownsin communication, ineffective teamworkand lack of compliance with processmeasures

Children’s hospital in the USAperforming numerous types of paediatricsurgery

At this hospital they had been building aquality infrastructure for 5 years prior, andhad already implemented the UniversalProtocol

Styer et al[2011]29

2008 WHO checklist modified andimplemented as hospital policy. Selectedmodifications listed. Checklist notincluded in publication

Qualitative description Implementing checklist using a PDSAcycle stepwise approach leads tosmoother transition and sustainedoutcomes

Teaching hospital in the USA with 44ORs

‘This initiative … was introduced to seehow the checklist might fit within ourhospital culture’

Bittle [2011]60 2008 WHO checklist adapted forindividual hospital. Checklist notincluded in publication

Qualitative description Checklists ‘ensure there is adherence toproven standards or care’

Large city hospital in New Zealand Quality service improvement team

Yuan [2012]14 2008 WHO checklist modified for localpractice. Checklist included in publication

Before and after study Checklists are an inexpensive and feasibleway to potentially improve quality ofsurgical care in ‘resource-limited settings’

Two hospitals (each with 2 ORs) inMonrovia, Liberia. Hospital 1 (150-bedprimary community hospital), hospital 2(200-bed, government referral hospital)

Liberia is rebuilding health systeminfrastructure after 14 years of conflict.Checklist implementation was acollaboration with the Ministry of Healthand Social Welfare in Liberia to characteriseits impact in low resource context

Kasatpibal et al[2012]34

2008 WHO checklist modified andtranslated. Hair removal added tochecklist. Other modifications notdescribed. Checklist not included inpublication

Case series Checklists may reduce preventableadverse surgical events, but may bedifficult or inappropriate to implement ina developing country

University hospital in northern Thailand(1400 beds, 21 877 operationsannually)

Average rate of surgical site infection inThailand is 1.7%

Bohmer et al[2012]30

2008 WHO checklist modified. Checklistincluded in publication

Before and after Checklists may improve staff’s perceptionof patient safety and job satisfaction

Institute for research in OperativeMedicine of the University of Witten/Herdecke

NR

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Fourcade et al[2012]27

2008 WHO checklist modified. Checklistincluded in publication

Case series1. Random sample of80 surgeries from eachcentre performed over18-day interval.2. Interviews andsurveys of participatingstaff

Checklists may improve surgicaloutcomes, but face barriers to efficientimplementation

18 cancer centres in France The French National Authority for Healthintroduced a modified checklist asmandatory. Implemented by FrenchNational Federation of Cancer Centresalong with research team fromCoordination for Measuring Performanceand Assuring Quality of Hospitals, InstitutGustave Roussy

Perez-Guisadoet al [2012]62

2008 WHO checklist. Checklist includedin publication

Descriptivecross-sectional study ofplastics, reconstructivesurgical procedures

Checklist ‘involves new philosophy oforganisation that is easier to achieve inhealth workers with lower hierarchy’ (ie,nurses, surgeon residents)

Reina Sofia Hospital (1684 surgeries) NR

van Klei et al[2012]33

2008 WHO checklist modified. Checklistavailable in online supplementarymaterial

Before and after Checklists enhance teamwork andimprove handovers decreased avoidableerrors and complications

University Medical centre Utrecht (TheNetherlands)

Checklist implemented in accordance withmandatory policy by the Dutch Health CareInspectorate

Takala et al[2011]63

2008 WHO checklist, modified. Checklistavailable in appendix

Before and after ‘Checklist would improve awareness ofsafety-related issues and the fluency ofoperations as well as communicationduring surgery’

Four university teaching hospitals inFinland

Pilot study to investigate usefulness of thechecklist in a variety of surgical specialtiesto inform development of a nationalchecklist

Truran et al[2011]64

2008 WHO checklist, modified. Checklistnot included

Before and after The checklist may improve compliancewith venous thromboembolismprophylaxis guidelines

Hospitals in the UK NR

Vogts et al[2011]32

2008 WHO checklist, modified. Checklistincluded in appendix

Case series Checklists ‘promote communication andteamwork within the OR’

Auckland City Hospital, New Zealand Checklist implemented 2 years prior

Askarian et al[2011]35

2008 WHO checklist. No modificationsnoted, checklist not included inpublication

Before and after Checklist may improve patient safety byreducing surgical complications

Referral educational hospital in Shiraz,southern Iran (374 beds, 6 ORs)

The Iranian Ministry of Health, Treatmentand Medical Education approvednationwide use of checklist in 2009

Levy et al[2012]31

2008 WHO checklist modified. Modifiedchecklist not included in publication

Case series Low fidelity of checklist execution may bea barrier to improving health outcomes

Academic tertiary care children’s hospital(Texas, USA)

Checklist compliance reported at 100%,but fidelity of checklist use is unclear


WHO checklist (unclear if modified).Checklist not included in publication

Case series ‘This checklist has reduced complicationsand deaths significantly’

Otorhinolaryngology department in fourFinnish hospitals

Checklist implemented in these hospitalsduring WHO pilot project in 2009

GI, gastrointestinal; GYN, gynaecology; NR, not reported; OR, operating room; PDSA, plan–do–study–act.

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Table 3 Findings of implementation studies of the WHO Surgical Safety Checklist

Author/year TrainingStudy phases and checklistfidelity Reasons for success or failure

Opinions, knowledge andbehaviour Health outcomes

Sewell et al[2011]24

Checklist forms placed in ORs,compulsory training video detailingcorrect and incorrect uses of thechecklist, emphasis placed on allteam members being responsible.Active discouragement of a simpletickbox approach. Checklist trainingwas not associated with reductionsin any complications or mortality

Training phase first (unreportedduration). Post-training period June–October 2009 (485 operations).Correct checklist use 97%: 2 min.20% thought it caused anunnecessary time delay

‘The initial implementation of thechecklist was met with resistance bysome operating room team membersas there was a belief that many ofthe points were already in practice’

77% thought it improved teamcommunication, 68% thought itimproved patient safety, 80% wouldwant the checklist used if they werehaving an operation

Early complications 8.5% beforechecklist training and 7.6% after.Mortality 1.9% before checklisttraining and 1.6% after. Lowerrespiratory tract infections 2.1%before checklist training and 2.5%after. Surgical site infection 4.4%before checklist training and 3.5%after. Unplanned return to OR 1.0%before checklist training and 1.0%after


Training involved a presentation froman outside expert and three 45 minlectures. Specific guidelines were inthe OR, and short instructions onthe back of the checklist

One-month implementation period inSeptember 2009 (443 operations)

‘Use of the checklist improvedverification of patient identity, but thiswas still inadequate.’ ‘Our studyconfirms that the surgical checklist fitswell into otolaryngology.’ ‘Werecommend the use of this checklistin all operations’

‘… overall, the operating roompersonnel were supportive’.Anaesthesiologists’ knowledge aboutpatients had improved compared withthe pre-implementation period.Preoperative check of anaesthesiaequipment increased from 71% to84%. After implementation, staff weremore likely to accurately report patientidentity, procedure and operative side.After implementation, there wasimprovement in: knowledge ofOR-teams’ names and roles rangedfrom 81% to 94%. Discussing risks was38%. Postop instructions recorded86%. Successful communication 87–96%

NR

Conley et al[2011]28

NR Duration of rollout: <2 months atthree hospitals, >6 months at twohospitals

The key is whether the localchampion can ‘persuasively explainwhy and adaptively show how to usethe checklist.’ Implementation wasincomplete at three hospitals: Onecancelled attempts to implement thechecklist due to ‘fear ofinsurmountable resistance and poorinterdisciplinary communication’.Another cancelled attempts becausethey were unable to move beyondpilot testing. The third had lesseffective implementation because of alaissez-faire leadership style; notraining; staff understood neither why

Interviews conducted, but noquantitative summary of opinionsprovided. Three hospitals werediscussed in detail

NR

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nor how the checklist could beimplemented

Bell and Pontin[2010]56, Bell57

Training provided to prevent‘teething problems.’ Instead ofrequiring paperwork, they used ineach OR an A3 board (a drawingboard about 14×20 inches) that wascolour-coded to aid completion.Publicity campaign in both hospitals

Piloted the checklist at one of the twohospitals first

‘To implement the checklisteffectively, it was essential to engageall staff to ensure the theatre teamworked together.’ ‘Working withindividuals to identify any gaps orissues with implementation.’ Currentlyit is ‘being used as standardthroughout theatres’

‘Communication and staff morale havedefinitely improved since the checklistwas implemented’

NR

Sparkes andRylah [2010]58

“Extensive educational support andtraining”

3-month pilot, during which changesto the checklist were made. After thepilot, and training, the checklist wasintroduced to all 29 ORs in November2009

Even though people agreed with thechecklist in theory, it was difficult tochange attitudes and behaviours,particularly the senior team. Thechecklist was required to be signed byteam members and ‘This had led tothe fear that legal colleagues willapportion blame to those who havesigned the checklist whencomplications occur’

Before checklist introduction: ‘Althoughall found the checklist to be useful,many senior clinicians felt that suchcommunication already took placeinformally, and that more paperworkwould not add to safety.’ Audit of 250cases in February 2010 found that teambriefings occurred in 77% and timeouts in 86%

NR

Royal Bolton[2010]36

Drop-in educational sessions whichinvolve 120 participants

May and June 2009 were spentgetting the word out about plans tostart using the checklist. Piloted firstfor 1 month in two of the Trust’shospitals in 62 operations. September2009 was the trust-wide launch of thechecklist. ‘Every Trust is different butimplementing the checklist across theTrust rather than a prolonged pilotperiod.’ Within the first week 33% ofoperations employed the checklist. By1 month it was at 72%. Currently alleight ORs use it

‘The importance of communicatingwith and involving people beyond thiscore group was recognised straightaway.’ ‘Essentially it is all aboutchanging the culture, which can be along process, but it’s well worth it’

‘The feedback we received from staffwas very positive. Most people werekeen to introduce the checklist asquickly as possible’

1-month pilot identified ninepotential incidents that were avoidedas a result of the checklist

Vats et al[2010]26

Limited time given to training Checklist accelerated with use. Largevariability in how the checklist wasused: sometimes incompletely, hurried,dismissive replies, and without somekey participants. Compliance wasinitially good, then fell when theresearch team was absent, and so theteam had to re-enter ORs toencourage greater use. Compliance

Need a local champion as well aslocal organisational leadership.Importance of being able to modifyto fit local needs, for example, therewas no need to check pulse oximetrybecause it is already always used

Anaesthetists and nurses were ‘largelysupportive’. Some surgeons were ‘notvery enthusiastic’. Awkwardself-introductions, takes time to achievecomfort, steep interpersonal hierarchy,ID the patient BEFORE draping, notafter. Complaints about duplication;perhaps a revised checklist could haveless duplication

‘At our hospital, we found nosignificant change in overallmorbidity or mortality, which werealready very low, after theintroduction of the checklist.However, there was a noticeableimprovement in safety processes,such as timely use of prophylacticantibiotics, which rose from 57% to

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ranged from 42% to 80% in the6-month period

77% of operations after the checklistwas introduced’

Kearns et al[2011]25

Training, humorous posters provided,and ‘all staff empowered to remindthe team to perform the checklist ifit was forgotten.’

Compliance with the preoperative partof the checklist was 61% after3 months and 80% after 1 year.Compliance with the postoperativepart of the checklist was 68% after3 months and 85% after 1 year

Authors cited four contributors tosuccess: allocation of responsibilities,local champion, sense of ownershipby team members, and ongoing staffconsultation

Staff attitudes 3 months after checklistintroduction: 50% now ‘felt familiar’with others in the OR; 70% feltcommunication had improved; 80% feltthat in elective cases the checklist wasuseful; 30% felt that in emergencycases the checklist was inconvenient.Fifty-eight patients were asked whetherthey noticed the operating teamperforming a series of checks before theoperation, and 75% said they did, andanother 19% remembered it after beingprompted. Of the combined 94%, theyall disagreed with the idea that thechecks would make them worried, and93% said they were reassuring

NR

Norton andRangel [2010]59

3×5 foot posters in each OR. Launchinvolved formal letter to staff,electronic training application,multiple in-service training sessions,and mention in hospital newsletter

December 2008 pilot test in sixpaediatric surgical services (general,neuro, orthopaedic, otolaryngology,plastic surgery, and urology). February2009 pilot test on the revisedprocedures, and more minor edits weremade. ‘Go-live’ date 1 April 2009 inall of the hospital’s ORs. Surgicalchiefs were local champions, and onenurse champion was paired with eachsurgeon champion. They divided theresponsibility for leading the Time Outphase among all team members, andidentified key speaking points.Compliance at ORs improved over timeduring this period from July 2009 toFebruary 2010

‘Use of the Paediatric Surgical SafetyChecklist encourages multidisciplinaryteamwork and has brought increasedcommunication to our ORs and inother areas’

December 2008 pilot test of 30procedures had 80–90% compliance,with ‘overwhelmingly positive’ feedback.‘Team members have expressedsatisfaction with the flow and contentof the checklist’

Checklist caught one near missduring sign in (site not marked),several near misses during time out,(antibiotics not given, problems withconsent forms, site marking notvisible after draping, missingequipment), and sign out (one teamrealised a patient needed straightcatheterisation, and reviewingprocedure name helped nursedocumentation, one specimen wasincorrectly labelled)

Styer et al[2011]29

Slide presentations, educationalposters in ORs, one on one sessions,frequent email updates

October 2008, 2-week trial. Day 1:checklist used by 2 surgeons;anaesthesia/nursing teams recruited toparticipate and provide same dayfeedback. Day 2: feedbackincorporated, used in 4 ORs, with 8surgeonsDecember 2008: chiefs of nursing,surgery, anaesthesiology and surgicalservices asked to endorse use as

Early endorsement by executiveleadership. Each discipline equallyinvolved in leading effort. PDSA cyclemethod for gradual implementation.Real-time feedback. Each disciplineshould lead a section of checklist.Provide data (process and outcomemeasures). Checklist adopted ashospital policy

NR Allergies: RN added recent newallergy to recordAntibiotics: not given (3), wrongantibiotic for procedure (2), surgeonchanged mind about giving antibioticafter confirming procedure, antibioticleft in another roomDVT: scheduled procedure typicallywould not have required compressionboots, but patient found to have

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hospital policyFebruary 2008: checklist teamestablished (leaders from surgery,anaesthesia, nursing), projectmanager, administrative fellowMarch 2009: staggered 14-weekrollout to 44 ORs. Each surgicalservice allotted 4 dedicated weeks ofattention (week 1: communication,week 2: education, week 3: go live,week 4: follow-up). During ‘go live’period, checklist team observerassigned to each surgery to educate,provide real-time feedback, answerquestions

history of DVTSafety precautions: heparin drip hadnot been discontinuedPlan for management of patient:chest radiograph after procedure forunsuccessful central line placementhad been forgotten

Bittle [2011]60 Quality division ‘coaches’ educatedOR teams about checklist, andbenefits

May 2010: ‘coaches’ from qualitydivision assigned to OR to introducechecklist, first to plastics, then otherspecialties. Team meetings with coach,OR manager, specialty clinical nursemanager, head of surgical departmentand senior registrars precededimplementation. Feedback regardingchecklist procedure obtained at 1 and3 weeks

NR Initially ‘staff were anxious andsomewhat apprehensive, but it is nowan established step in an operation andis carried out with confidence’

Incorrect surgery site pointed out bypatientReported incidents fell from 12 to 11compared with reporting period ofprevious year

Yuan et al[2012]14

Certified registered nurseanaesthetists (CRNAs) wereidentified as local leaders of surgicalteams. CRNAs along with surgeons,OR staff participated in 2-weektraining of lectures, written materialsand direct guidanceLarge printed poster placed in ORs

Two months prior and after. Allpatients followed prospectively foroutcomes and complications untildischarge or 30 days, whichever camefirst

Reasons for success: checklistimplementation catalysed efforts toprocure equipment (ie, pulseoximeter) necessary for safetyprocessesReasons for failure include: lack ofconsistent access to crucial resources(such as antibiotics, batteries);checklist ‘did little to change theentrenched hierarchy and relationshipdynamics of OR staff’; lack ofsustained checklist training beyond2 weeks

‘… the checklist’s focus on continuousimprovement helped to foster a shift inmind-set among staff who were “justused to making it to the end of theday” to building a stronger culture ofsafety’

Checklist associated with overallimproved adherence to ≥4 (out of 6)safety processes, decreased surgicalsite infections (AOR 0.28, 95% CI0.15 to 0.54), surgical complications(AOR 0.45, 95% CI 0.26 to 0.78)Stratified analysis revealed improvedadherence limited to hospital 1 (AOR4.06, 95% CI 2.2 to 7.6), decreasedsurgical site infections, surgicalcomplications limited to hospital 2No improvement in surgicaloutcomes

Kasatpibal et al[2012]34

Circulating OR nurse participated intwo meetings and 1-day datacollection training session

From March 2009 to August 2009,42.6% of operations selected forinclusion91% of patients confirmed identity,site, procedure and gave consent. Only19% of surgical sites marked.Anaesthesia equipment and

Compliance with marking of surgicalsite low because: marking materialsunavailable, procedure was emergent,and ‘Thai culture’ in which ‘Thais donot make marks on other people,especially on the head’Also, ‘some surgeons assumed that

Surgical teams often did not introducethemselves during time out for culturalreasons. ‘In Thai culture, people usuallyintroduce themselves only when theyfirst meet someone and are shy aboutpublicising their roles’Compliance with checklist high for

NR

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medication checked in 90% of cases.Pulse oximeter applied in 95% ofcases. Allergies, difficulty airway,aspiration risk and risk of >500 mLblood loss assessed in 100% of cases

wrong-site surgery would not occurbecause they had not experienced itthemselves’Compliance with hair removalprocedures was hampered by lack offamiliarity with proper procedure, lackof equipment and requests fromsurgeons

life-threatening issues (drug allergies,difficult airways, profuse blood loss) andconfirmation of patient’s name, incisionand procedure. Notably, standards forthese measures are already currenthospital policyCompliance was low for surgical sitemarking and appropriate hair removal

Bohmer et al[2012]30

NR Survey administered before checklistimplementation, then 12 weeks afterimplementation

All participating specialties wereinvolved in formulation of thequestionnaireThe checklist was modified for ‘localconditions’ based on feedback fromstaffChecklist introduced by departmentheads, demonstrating leadershipBaseline findings and improvementafter introduction of the checklistwere presented to staff

OR staff felt that communication culturein OR was improved, and checklistfacilitated information aboutintraoperative complications. Theauthors observed there was morediscussion of critical events betweensurgeons/anaesthesiologists

NR

Fourcade et al[2012]27

NRTraining sessions, written materialsand videos available from the FrenchNational Authority for Health, butuse by participating centres was notreported

11–29 January 2010. Random sampleof 80 records from medical record percentre were analysedExcluded topical anaesthesia, IR, GIendoscopy and CVC placementSubsequent interviews with staff andsurgeons via semi-structured interviewsand email surveys

Barriers to success:1. Many elements of checklist alreadyexist so checklist creates duplication2. Poor communication betweensurgeon/anaesthetist3. Completing checklist took toomuch time, staff did perceive benefit4. Some items confusing becausethey did not fit in with customary ORpractices (or seemed inappropriatelytimed)5. High staff turnover, new staffunfamiliar with checklist.6. If OR staff not actively engagedduring checklist, nurses felt concernedabout ‘legal implications of signingthe checklist as they might be heldaccountable for errors’7. Some felt questions wererepetitive, might frighten patientsabout to undergo anaesthesia8. In 5 centres, box for checklistcould be checked if safety check notperformed for time constraints. Somestaff worried this would make

Checklist performed in 90.2% ofsurgeries. However, checklist wascompleted in only 61% of cases

NR

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checklists fail to improve patientsafety

Perez-Guisadoet al [2012]62

NR January–December 2010Responsibility for sections of checklistwas divided between nurses,anaesthetists and surgeons

Local 10-question checklist already inplace, containing 8 items from WHOchecklist

Nurses achieved 99% implementation,but surgeons and anaesthetists onlycompleted checklists 79% and 72% oftime, respectively

NR

van Klei et al[2012]33

Information provided in regularmeetings to OR staff. Posters placedin all ORs and electronic systems

1 January 2007–30 September 2010Checklist implemented 1 April 2009Monthly compliance reports providedto team managers. OR circulatingnurses designated in charge ofchecklist completion

Checklist completion may benecessary for improved healthoutcomesChecklist may be less likely to becompleted in patients undergoingemergency surgery who are at higherrisk of mortality. This raisesmethodological questions of how toadjust for patient severity

Checklist fully completed in 39% of allpatients. Median number of itemsdocumented was 16

After implementation, 30-dayin-house mortality decreased from3.13% to 2.85%. Checklistassociated with decreased odds of30-day mortality (AOR 0.85, 95% CI0.73 to 0.98)Incomplete checklist did not have asignificant effect on mortality

Takala et al[2011]63

‘Brief instructions on the use of thechecklist were on the checklistbackside. Written guidelines on howto use the checklist were alsoavailable. Instructions were given inorder to avoid variation in the use ofthe checklist in different hospitalsand operating theatres’

Study initiated in 2009Nurses, anaesthetists and surgeonssurveyed regarding OR practicesThen, the checklist was implementedover 2–4 weeksFinally, survey of OR practices repeated4–6 weeks after checklistimplementation

NR Nurses, anaesthetists and surgeonsreported increased confirmation ofpatient identity and awareness ofnames/roles of team membersSurgeons reported improvements indiscussions of critical events withanaesthesiologist (34.7–46.2%,p<0.001) and gave prescriptions andinstructions to post-anaesthesia careunit more often

Implementation led to discovery ofsystematic error in timing ofprophylactic antibiotics administration

Truran et al[2011]64

NR Checklist introduced April 2009Study evaluated compliance with NICEvenous thromboembolism prophylaxisguidelines for 3-week period prior tochecklist implementation, and6 months afterwards

NR Non-compliance with guidelines forvenous thromboembolism prophylaxisdecreased after checklist from 6.9% to2.1%

NR

Vogts et al[2011]32

NR November–December 2010Medical student observed 100procedures, documented compliance

Authors suggest compliance with‘sign out’ section is low because thetiming is ‘not linked to a specificevent in patient management’ andnurses tasked with performing thissection have many competingresponsibilities at the end ofprocedure

Compliance with ‘sign in’ and ‘time out’sections of checklist was high. However,‘sign out’ was only observed in 2/100cases

NR

Askarian et al[2011]35

Checklist presented to OR headEducational packages containingchecklist and guidelines weredistributed to surgeons, assistants,

Included all elective general surgeries3 months prior to checklist, followedby 3 months after implementation(144 patients)

NR Obtaining information for time out andsign out sections of checklist improvedafter checklist implemented

Surgical complications (beforedischarge) decreased from 22.9% to10% after checklist implementationSurgical site infections decreased

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anaesthetists and nursesChecklist presented to OR teams

Levy et al[2012]31

All OR team members exceptphysicians viewed a computer-basedtraining presentation one timeLarge poster of checklist placed inevery OR

Direct observation of randomlyselected non-emergent surgeries over7-week period

Inadequate education duringimplementation led to confusionregarding practical execution ofchecklist. (Unclear if physiciansreceived any training)Checklist poster in OR lacked practicalinstructions for how checklist shouldbe executed, including which teammembers questions are directedtowardsChecklist was not adapted forpaediatric patients and may havebeen less relevant

Although electronic medical recordreported 100% compliance, only 4/172cases completed more than 7 out of 13checkpointsSmall post-study survey of OR staffrevealed confusion about proper timingof ‘time-out’ and team memberresponsible for ensuring checklistexecution

NR


OR staff heard three informativelectures before participating in WHOpilot studySpecific guidelines on use ofchecklist were available in the ORBrief instructions appeared on theback of the checklist

Checklist implemented in September2010. All surgeries (7148) betweenSeptember 2010 and August 2011includedSurvey administered October 2011

Nurses reported ‘some seniorotolaryngologists had negativeattitudes towards the checklist’‘Active leadership, regular audits andfeedback are important for successfulimplementation and maintenance of achecklist’

Checklist completion rates were: sign in62.3%, time out 61.1%, sign out53.6%76% of OR team agreed checklistimproved OR safety, 68% agreed itimproved error prevention, 93% wouldwant checklist used during their ownsurgeryDisregard for checklist use was revealedin the open responses: ‘answers aredismissive’, ‘it is noisy and staff is notconcentrating on the checks’ … Onesenior otolaryngologist wrote, ‘Time outhas never been performed in myoperations’. In addition, there wasconfusion about who should lead eachcheck section and when to do checks: ‘Ihave never received the information onhow to use the checklist’Positive comments included ‘thechecklist is beneficial’, ‘it should alwaysbe used’ and ‘nowadays no operationshould be varied out without thechecklist’

NR

AOR, adjusted odds ratio; NICE, National Institute for Health and Clinical Excellence; NR, not reported; OR, operating room; PDSA, plan–do–study–act.

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EDUCATION AND COMPLIANCERegarding checklist training, 10 sites mentioned edu-cational sessions, seven used posters in the OR, twomentioned a hospital-wide publicity campaign, twomentioned that training was provided (however nodetails were given), and eight either failed to mentiontraining or stated that only limited training was pro-vided. Six studies mentioned a pilot testing period;these pilot tests lasted 1–3 months and often resultedin minor modifications to the checklist.Nine studies reported the degree of compliance

with the checklist; one simply reported 97% compli-ance, and two others reported improvement over time(from approximately 60% to 80% in one study, andfrom 85% to 95% in another study). Notably, whilecompliance with checklist use was high, the checklistswere often left incomplete. Fourcade et al27 reportedchecklist use in 90.2% of surgeries, but completion inonly 61%. Similarly, Levy et al31 found that althoughchecklist compliance was 100% in the electronicmedical record, only 4 of 172 checklists completedmore than 7 out of 13 required checklist items.Kasatpibal et al34 reported that staff had high compli-ance with checklist items which had already beenstandard hospital policy, but low compliance forchecklist items not routinely practiced.

SURPASS checklistOur searches identified no attempts to use theSURPASS checklist outside the Netherlands. Thewebsite (http://www.surpass-checklist.nl/home.jsf?lang=en) describes a web version of the checklist(called SURPASS Digital), which allows one to modifythe checklist, although the designers of SURPASSstrongly discourage it (http://www.surpass-checklist.nl/content.jsf?pageId=FAQ&lang=en).

Wrong-site surgery checklistsWe identified four sites describing checklists based onthe Joint Commission’s UP (table 4). The Swissstudy37 focused on verifying patient identity and sur-gical site. Compared with the first 3 months of imple-mentation, the next 3 months saw better compliancein checking patient identity and proportion of surgicalsite checks performed. Barriers to implementationincluded surgeons saying they already knew thepatients or the surgical site was obvious, and thefailure to include the input of all surgical services indeveloping the protocol.The Swedish study38 involved two hospitals, each of

which had a recent wrong-site surgery incident, and aroot-cause analysis suggested that a time-out proced-ure might help. A time-out checklist was implemen-ted, and 1 year later, a questionnaire showed that93% of team members believed the checklist contribu-ted to patient safety.The English study39 was conducted at a children’s

hospital in which staff had incorporated an eight-item

correct-site surgery checklist into an existing surgicalchecklist. Comparing 2008 with 2006, correct com-pletion was improved for four of the eight checklistitems.The North Carolina study37 implemented a check-

list to prevent wrong-site surgery that was tailored tothe hospital’s preferences and procedures. Staff com-mented favourably that they no longer had to remem-ber everything on a cumbersome form.No implementation advice was found on the Joint

Commission website or in other published documents.In August 2010, the Joint Commission conducted anonline survey of over 2100 people.40 The websitereports high agreement that organisations can fullyimplement the UP, its three steps are appropriate, andthat ‘there is benefit’ in using it in the OR, ambulatorysurgery and hospital units performing invasive proce-dures (but the rates of agreement of benefit werelower for ambulatory clinics and physician offices).The need to modify policies and procedures variedgreatly across respondents, and no differences werefound between different types of respondents (eg,type of hospital, bed size).

COSTSCosts of implementing a checklist mostly involvechecklist development and/or modification, formalstaff notification, training and additional OR time. In2010, Semel et al41 performed a hypothetical decisionanalysis of checklist introduction. The cost was esti-mated using the ‘opportunity cost of the work thatwould have otherwise been performed by the threedepartment checklist champions and the implementa-tion coordinator’, which was an estimated $12 635 in2008 dollars; per-use cost was only $11. But the costof a major surgical complication was estimated at$13 372. In the base case, checklist introduction savedmoney.Regarding time, Sewell et al24 reported that 20% of

staff thought the WHO checklist caused an unneces-sary time delay. However, in 2011, Taylor et al16

reported that the WHO checklist took only about2 min on average.

ADOPTION AND DIFFUSIONOn 15 May 2013, the WHO’s Surgical Safety WebMap (http://maps.cga.harvard.edu:8080/Hospital/)indicated that as of 26 March 2012, 4132 hospitalshad expressed interest in using the checklist and 1790of these hospitals have used the checklist in at leastone operating theatre.Many professional organisations have recommended

adoption of the WHO checklist. These include theInstitute for Healthcare Improvement (http://www.ihi.org), the National Patient Safety Agency in the UK(http://www.nrls.npsa.nhs.uk),42 43 the Canadian PatientSafety Institute,44 45 the Washington State Surgical Careand Outcome Assessment Program46 (http://www.scoap.

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ownloaded from

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http://maps.cga.harvard.edu:8080/Hospital/

http://maps.cga.harvard.edu:8080/Hospital/

http://www.ihi.org

http://www.ihi.org

http://www.ihi.org

http://www.nrls.npsa.nhs.uk

http://www.nrls.npsa.nhs.uk

http://www.scoap.org



Table 4 Studies of wrong-site-surgery checklists implementing the Universal Protocol

Author/year Description of PSP Study design Theory or logic modelDescription oforganisation Safety context Implementation details

Garnerinet al[2008]37

Verification protocol forchecking patientidentity and the site ofsurgery

Case series ‘… the prevention of wrong patientsand wrong site surgery, not to mentionaccountability, demanded anintervention aimed at improving theway both patient identity and site ofsurgery checks were performed, whileacquiring the ability to identify andcorrect deficiencies’

Swiss anaesthesiologyservice located within a1200-bed universityhospital

Prior to introduction of the checklist, allpatients were required to wear IDbracelets, and the operative site had to besigned by the surgeon. Anaesthesiologistswere made aware that they were beingmonitored

Verification protocol developed by aninterdisciplinary team. It required patientsto state their identity, comparing thestatement to the ID bracelet, OR schedule,and medical record. Similar types of checksfor correct site of surgery. Nine consecutivemonths of data were obtained (October2003–June 2004), and later 3 subsequentmonths (October 2004, March 2005 andOctober 2005)Compared with the first 3 months ofimplementation, the next 3 months sawbetter compliance in checking patientidentify (63% up to 81%), completecompliance with identity checks (10% upto 38%), proportion of surgical site checksperformed (77% up to 93%), andcomplete compliance with surgical sitechecks (32% up to 52%). Compliance wasstable in subsequent periodsAuthors attributed the improvements toincreased use of wristbands uponadmission into the and the use of threedifferent sources for verificationBarriers included surgeons saying theyalready knew that patients or the surgicalsite was obvious, and the failure to developthe protocol with the input of all surgicalservices

Nilsson et al[2010]38

Preoperative ‘time-out’checklist

Questionnaireafterimplementation

None explicitly stated Two Swedish hospitals,bed sizes not reported

In the autumn of 2007, there were twoincidents of wrong-side surgery at thesehospitals, and a root-causes analysissuggested that a time-out procedure mighthelp. The checklist was pre-approved bythe heads of the operating andanaesthesia departments

Implementation began in December 2007.The checklist was a shared responsibility ofthe OR team. One year later, aquestionnaire was sent to all 704 surgeons,anaesthesiologists, operation nurses,anaesthetic nurses, and nurse assistants,soliciting their opinions about the newtime-out checklist. Of the 331 responders,93% felt that the checklist contributed toincreased patient safety (either ‘without adoubt’ or ‘probably’). When asked abouteight specific components of the time-outchecklists, the percentage of respondentswho felt the component was ‘veryimportant’ varied widely, from a low of

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Author/year Description of PSP Study design Theory or logic modelDescription oforganisation Safety context Implementation details

14% for the introduction of team membersto highs of over 80% for patient identity,correct procedure, and correct side.Regarding the sign-out, 91% felt that theitem involving the count of surgicalinstruments and sponges was veryimportant

Owers et al[2010]39

Correct site surgerychecklist incorporatedinto an existing surgicalchecklist

Case series None explicitly stated English children’shospital, bed size notreported

A surgical checklist already existed at thisfacility; they added a correct site surgerycomponent

Five people were required to sign thedocumentation: marking surgeon, operatingsurgeon, ward nurse, scrub nurse andanaesthetist. Two audit cycles: once in2006 (sooner after implementation) andonce in 2008 (2 years later). Comparing2008 with 2006, correct completion of theeight items was not at all improved for fouritems (ward nurse signed, operatingsurgeon signed, scrub nurse signed, andoperating department practitioner signed)but was improved for the other four (marksite documented, no mark requireddocumented, entries legible, and markingsurgeon signed).‘The lack ofdocumentation, of course, may not reflectthat the new guidance and processes arenot being followed, but rather that thedocumentation is regarded as a low prioritypart of the process’

Anonymous200765

Checklist to implementthe Universal Protocol,tailored to thishospital’s preferencesand procedures

Case series Stated that the checklist provides cuesfor staff when preparing for aprocedure

Hospital in NorthCarolina, bed size notreported

Before this checklist, they were using a‘cumbersome form’ to document theircompliance with the Universal Protocol

Original checklist in 2005, minor revisionsfor 2006. Demonstrated the checklistduring educational staff meetings, and newstaff were given a primer. Staff gavepositive comments that they no longer hadto remember everything. The completedchecklist is kept as part of the medicalrecord

OR, operating room.

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org), the South Carolina Hospital Association,44 theSpanish Ministry of Health and Spanish Association ofSurgeons,47 and the countries of France,44 Ireland,48

Jordan48 and the Netherlands.33 Furthermore, severalorganisations in Australia and New Zealand have devel-oped modified versions of the WHO checklist: theRoyal Australasian College of Surgeons, the Australianand New Zealand College of Anaesthetists, the RoyalAustralian and New Zealand College of Obstetriciansand Gynecologists, the Australian College of OperatingRoom Nurses, and the Australian Commission forSafety and Quality in Health Care.49

Sivathasan and colleagues50 conducted telephoneinterviews with 238 hospitals in the UK. Almost all(99%) of the hospitals had heard of the checklist, andits use was already compulsory in 65% of them. In hos-pitals where it was not required, 81% used it voluntar-ily and 75% planned to make it mandatory in thefuture. Notably, some ORs reported partial use of thechecklist, that is, intentionally skipping items or skip-ping the entire checklist because of time constraints.In June 2009, the journal OR Manager received

online data from 136 subscribers regarding use of theWHO checklist.51 Nearly half (48.5%) reported imple-menting the checklist and 64% said the checklist hadimproved safety in the OR. However, 11% of respon-dents stated that the checklist was not well accepted bysurgeons and another 63% said surgeons did accept itbut ‘with reservations.’ Nurses were found to have asomewhat greater degree of acceptance.A 2009 UK survey of 12 oral and maxillofacial con-

sultants found that all were aware of the WHO check-list, but only 5 of 12 were actually using it.52 Ten of12 expressed the belief that it would improve patientsafety, but 4 of 12 said it would not improve teamcommunication.Regarding the UP, accredited hospitals are required

to comply. Therefore the ‘diffusion’ of the UP is large,by mandate. However, as stated earlier, the UP is nota checklist. We found no published information onhow many hospitals actually use a checklist in theirefforts to comply.

DISCUSSIONSeveral prominent authorities in the field of patientsafety have promoted checklists in an attempt toprevent mistakes related to surgery. Our report demon-strates that checklists have been widely adopted, notonly in Western countries, but in diverse contextsthroughout the world. Notably, we found evidencethat checklists are associated with improved health out-comes, including decreased surgical complications andsurgical site infections. Association, however, does notimply causation. Thus, we note three importantcaveats. First, checklists are often implemented as partof a multifaceted strategy to improve care, which mayrender it difficult to determine whether improvementsshould be attributed to checklists alone or to other

changes such as improved communication and shifts inOR culture. Second, reporting bias may have played arole. Eleven out of 21 implementation studies did notreport health outcomes, potentially due to an absenceof clear improvements after checklist implementation.Third, the reported results do not mean that all surgi-cal checklists are beneficial; other surgical checklistscontaining different items may or may not bebeneficial.Many surgical staff have reported favourable atti-

tudes towards checklist implementation. However,numerous implementation issues remain, includinghow to modify a given checklist to a specific hospitalsetting or specific surgical staff. Our report found thatbarriers to effective implementation include confusionregarding practical aspects of checklist use, dealingwith challenges to efficient workflow, obtainingregular access to resources and the beliefs and atti-tudes of participating staff, particularly surgeons. Onerecurrent theme in the literature on surgical checklistsis the explicit encouragement of a team-basedapproach. The AHRQ continues to investigate factorssupportive of effective checklist implementation withthe 2010–2013 project entitled, ‘Factors associatedwith effective implementation of a surgical safetychecklist’.53 This project will elucidate how teamworkmay contribute to the impact of the checklist.The WHO checklist’s wide adoption and dissemin-

ation suggests it may serve as a model for policy-makers seeking to develop safety strategies in thefuture. This checklist was explicitly designed to bemodified for widely varying contexts and executed ina short time frame to maintain feasibility. The WHOwebsite instructs hospitals: ‘Do not hesitate to custom-ise the checklist for your setting as necessary, but donot remove safety steps just because you are unable toaccomplish them’ and emphasises that ‘It should takeno more than a minute to complete each section ofthe checklist’ (ie, 3 min in total).54 The pilot studyreported that, at various sites, introduction of thechecklist took only 1 week to 1 month.5 Checklistimplementation is relatively inexpensive, with somehospitals simply printing posters to be hung on ORwalls. These practical characteristics of the WHOchecklist may have significantly promoted its uptakeand use. Notably, the WHO approach markedlydiffers from that stated by creators of the SURPASSchecklist, who strongly discouraged its adaption.Although SURPASS is more comprehensive, it has notbeen widely implemented, potentially due to theresource intensive effort required to track patientsthroughout a surgical hospitalisation.In conclusion, the WHO checklist, the SURPASS

checklist and checklists implementing the JointCommission UP represent promising initiatives withsuggestive evidence for improving patient safety. Futureresearch may clarify the unique nature of their contribu-tion and provide insights for effective implementation.

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Key summary points

▸ Surgical checklists such as the WHO Surgical SafetyChecklist and Surgical Patient Safety System(SURPASS) checklist offer a promising intervention fordecreasing patient morbidity and mortality due tosurgical operations.

▸ The WHO Surgical Safety Checklist has been success-fully adapted for implementation in a wide variety ofsettings, including all surgical specialties, academicand community hospitals, and industrialised anddeveloping countries.

▸ Surgical safety checklists were associated withincreased detection of potential safety hazards,decreased surgical complications and improved com-munication among operating room staff. Other factorsindependent of checklists, such as concurrent safetyimprovements, may also explain these improvements.

▸ Key components of successful checklist implementationinclude enlisting support from institutional leaders,training staff on using the checklist, adapting thechecklist to incorporate staff feedback and avoiding theduplication of information already routinely collected.

Acknowledgements The authors wish to thank Allison Gross,MS, MLS for performing literature searches, and KarenSchoelles, MD, SM and Paul Shekelle, MD, MPH, PhD forproject oversight.

Contributors JRT contributed to planning the review, reviewingabstracts, extracting data, writing text and editing text. SLcontributed to planning the review, reviewing abstracts,extracting data, writing text and editing text. AT contributed toextracting data, writing text and editing text.

Disclaimer All statements expressed in this work are those ofthe authors and should not in any way be construed as officialopinions or positions of the ECRI Institute, AHRQ, or the USDepartment of Health and Human Services.

Funding This work was supported by funding from the Agencyfor Healthcare Research and Quality (AHRQ), US Departmentof Health and Human Services (Contract NoHHSA-290-2007-10062I). AHRQ reviewed contractdeliverables to ensure adherence to contract requirements andquality, and a copyright release was obtained from AHRQ priorto submission of this manuscript.

Competing interests The authors declare no competingfinancial interests exist.

Provenance and peer review Not commissioned; externallypeer reviewed.

Open access This is an Open Access article distributed inaccordance with the Creative Commons Attribution NonCommercial (CC BY-NC 3.0) license, which permits others todistribute, remix, adapt, build upon this work non-commercially,and license their derivative works on different terms, provided theoriginal work is properly cited and the use is non-commercial.See: http://creativecommons.org/licenses/by-nc/3.0/

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