The WHO Surgical Safety Checklist: Its Relevance and Application to Different Perioperative Settings

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While surgical procedures account for an estimated 13% of total disability-adjusted life years worldwide, hazardous surgical practices can increase mortality [1]. Nearly half of surgery-related adverse events occur in the operating theatre, 44% of which are thought to be avoidable [2]. In June 2008, the World Health Organization (WHO) launched the Second Global Patient Safety Challenge: ‘Safe Surgery Saves Lives’. This initiative aimed to raise the standard of safety across surgeries worldwide by outlining a set of core safety practices [1]. International expert working groups reviewed the available literature and assessed current surgical practices before formulating the WHO Guidelines for Safe Surgery. A key component of the guidelines was the Surgical Safety Checklist (SSC) – a core set of safety checks to be used in any operating room as a means of improving communication among the entire surgical team and reinforcing safety practices [3].

The SSC is a complex document comprising 19 items split into three main sections, each of which is read aloud to try to ensure that pre- and postoperative safety measures are met. The first section should be completed with the patient before the induction of anaesthesia and reaffirms the patient’s identity and history (sign-in). The second and third sections take place in the operating theatre before (time-out) and after (sign-out) the procedure, respectively. These sections comprise a list of questions directed to different members of the surgical team, including the anaesthetist, nurse and surgeon, and provide a forum to highlight key concerns (Figure 1) [4].

Figure 1: WHO Surgical Safety Checklist

WHO Checklist NEW

The SSC was originally trialled in eight countries for 1 year, with results suggesting that a formalised system of planning and communication can significantly improve patient outcomes [5]. Data were collected on, respectively, 3,733 and 3,955 consecutively enrolled patients before and after induction of the SSC. The rate of death declined from 1.5% to 0.8% after introduction of the checklist (P=0.003) and inpatient complications reduced from 11% to 7% (P<0.001) [5].

Importantly, the trial countries comprised a range of economic backgrounds, and data suggested that significant improvements occurred in both higher- and lower-income settings [5]. Since then, more studies and case reports have been published, further supporting use of the SSC. The study by Haugen et al. is the first cluster randomised trial of the SSC [6]. Analysis focused on a cohort of patients in Norway with significant rates of morbidity and in-hospital mortality (19.9% and 1.6%, respectively). The study confirmed that the SSC significantly improved outcomes, with a relative risk (RR) reduction in major complications of 0.42 (95% confidence interval [CI] 0.33–0.50) [6]. A systematic review and meta-analysis, which included seven non-randomised controlled trials from Iran, Moldova, the Netherlands, the UK and the US, showed that use of the WHO SSC significantly reduced postoperative complications (RR 0.59; 95% CI 0.47–0.74; n=5), mortality (RR 0.77; 95% CI 0.60–0.98; n=4), and surgical-site infections (RR 0.57;
95% CI 0.41–0.79; n=5) [7]. Effective implementation of surgical checklists is also likely to reduce the long-term costs associated with surgeries and aftercare [8]. A cost–benefit model from the US predicted this could result in savings of up to $91.4m within public sectors over a 10-year period [9].

The introduction of the SSC has prompted checklists to be used in other perioperative settings, including ward rounds. Ward rounds are subject to time pressure and are often led by staff more senior than those updating patient notes, which raises concerns about the robustness of patient records. A standardised surgical ward round checklist has been trialled in multiple wards and has been shown to encourage standardisation of care and management of postoperative complications [10, 11]. Checklists modelled on the SSC but tailored to specific types of surgery have also been introduced; the use of a 10-item checklist during transurethral resection of bladder tumours was shown to improve reporting of critical procedural elements, which is likely to impact patient outcomes [12]. A preliminary study has also highlighted the potential use of a checklist to guide family communication in trauma care [13]. Checklists could, theoretically, be used throughout the entire perioperative setting to improve holistic care.

The WHO has formalised surgical care with the introduction of the SSC. In situations with increasing pressure and time constraints, taking the time to follow a set of core items has been shown to improve patient outcomes as well as long-term costs. The capability of checklists to support a variety of surgical processes and procedures has allowed their broad application to different perioperative settings.


  1. WHO. Safe surgery: Why safety is important. 2008. Accessed from: in June 2016.
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  13. Dennis BM et al. Using a Checklist to Improve Family Communication in Trauma Care. Am Surgeon 2016; 82: 59−64

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