Patient Safety

Safe Surgery
Why safe surgery is important
Surgical care has been an essential component of health care worldwide
for over a century. As the incidences of traumatic injuries, cancers and
cardiovascular disease continue to rise, the impact of surgical intervention
on public health systems will continue to grow.
Surgery is often the only therapy that can alleviate disabilities and reduce
the risk of death from common conditions. Every year, many millions of
people undergo surgical treatment, and surgical interventions account for
an estimated 13% of the worlds total disability-adjusted life years
(DALYs).
While surgical procedures are intended to save lives, unsafe surgical care
can cause substantial harm. Given the ubiquity of surgery, this has
signicant implications:

the reported crude mortality rate after major surgery is 0.55%;

complications after inpatient operations occur in up to 25% of

patients;

in industralized 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;

mortality from general anaesthesia alone is reported to be as

high as one in 150 in some parts of sub-Saharan Africa.
WHO and Surgical Safety
WHO has undertaken a number of global and regional initiatives to
address surgical safety. Much of this work has stemmed from the WHO
Second Global Patient Safety Challenge Safe Surgery Saves Lives. Safe
Surgery Saves Lives set about to improve the safety of surgical care
around the world by dening a core set of safety standards that could be
applied
in
all
WHO
Member
States.
To this end, working groups of international experts were convened to
review the literature and the experiences of clinicians around the world.
They reached consensus on four areas in which dramatic improvements
could be made in the safety of surgical care: surgical site infection
prevention, safe anaesthesia, safe surgical teams and measurement of
surgical services.
Safe Surgery Saves Lives Frequently Asked Questions
Why is the Checklist important?

234 million major operations are performed annually across

the world. This translates to roughly one operation for every 25
people and indicates that the safety of care is of signicant
public health importance. For more on this statistic and its
implications, see the following article in the Lancet:

Moreover, given previously estimated rates of major

complication and death following inpatient surgery, a
conservative estimate is that 7 million patients suffer
complications following surgery, half of which are probably
preventable.
What is the Checklist and how was it developed?

The WHO Surgical Safety Checklist is a 19-item tool that was

created by an international group of experts gathered by WHO
with the goal of improving the safety of patients undergoing
surgical procedures around the world. Anaesthetists, operating
theatre nurses, surgeons, patients and other professionals
were extensively involved in its development.

It involves the coordination of the operating team the

surgeons, anaesthesia providers, and nurses to discuss key
safety checks prior to specic phases of perioperative care: a
Sign In prior to the induction of anesthesia, a Time Out
prior to skin incision, and a Sign Out before the team leaves
the operating room. Many of the checks are already routine in
some institutions, but surprisingly, few operating teams
accomplish them all consistently, even in the most advanced
settings.
What were the ndings of the original trial?

Between October 2007 and September 2008, the effects of the

Checklist were studied in eight hospitals in eight cities
(Toronto, Canada; New Delhi, India; Amman, Jordan; Auckland,
New Zealand; Manila, The Philippines; Ifakara, Tanzania;
London, UK; and Seattle, USA) representing a wide variety of
economic circumstances and diverse patient populations. Data
was prospectively collected on clinical processes and outcomes
from 3733 patients before and 3955 patients after the
Checklist was implemented. The results of the study were
published in the New England Journal of Medicine on January
29, 2009 and demonstrated dramatic improvements in both
processes and outcomes. Indeed, use of the WHO Checklist
reduced the rate of deaths and complications by more than
one-third across all eight pilot hospitals. The rate of major
inpatient complications dropped from 11% to 7%, and the
inpatient death rate following major operations fell from 1.5%
to 0.8% after implementation of the Checklist. Moreover, the
effect was of similar magnitude in both high and low/middle
income
country
sites.
Has there been other evidence to support its use?

Other studies have gone on to support this nding (current as of January

2014):

Yuan CT, Walsh D, et al. Incorporating the World Health

Organization Surgical Safety Checklist into practice at two
hospitals in Liberia. Jt Comm J Qual Patient Saf 2012; 38: 254
60.

Sewell M, et al. Use of the WHO surgical safety checklist in

trauma and orthopaedic patients. International Orthopaedics
(SICOT) 2010; 35: 897901.

de Vries EN, et al. Effect of a comprehensive surgical safety

system on patient outcomes. New England Journal of Medicine
2010; 363: 192837.

Askarian M, et al. Effect of surgical safety checklists on

postoperative morbidity and mortality rates, Shiraz, Faghihy
Hospital, a 1-year study. Qual Manag Health Care 2011; 20:
2937.

Sewell et al. documented a decrease in early complications

from 8.5% to 7.6%, mortality from 1.9% to 1.6% and surgical
site infections from 4.4% to 3.5%:

Sewell M, et al. Use of the WHO surgical safety checklist in

trauma and orthopaedic patients. International Orthopaedics
(SICOT) 2010; 35: 897901.

Askarian et al. found that surgical complications decreased

from 22.9% to 10%:

Askarian M, et al. Effect of surgical safety checklists on

postoperative morbidity and mortality rates, Shiraz, Faghihy
Hospital, a 1-year study. Qual Manag Health Care 2011; 20:
2937
The Netherlands Surgical Patient Safety System found a signicant
reduction in in-hospital mortality (1.5% to 0.8%) and in overall
complications (27.3 to 16.7 per 100) after implementation of a
comprehensive surgical checklist:

de Vries EN, et al. Effect of a comprehensive surgical safety

system on patient outcomes. New England Journal of Medicine
2010; 363: 192837.
Improvements have been broader than just morbidity and mortality.

Semel et al. suggested that its use was cost-saving too:

Semel ME, et al. Adopting A Surgical Safety Checklist Could

Save Money And Improve The Quality Of Care In U.S. Hospitals.
Health Affairs 2010; 29: 15939.

Kearns et al. and Sewell et al. found most users felt the
Checklist improved communication:

Kearns RJ, et al. The introduction of a surgical safety checklist

in a tertiary referral obstetric centre. BMJ Quality & Safety
2011; 20: 81822.

Sewell M, et al. Use of the WHO surgical safety checklist in

trauma and orthopaedic patients. International Orthopaedics
(SICOT) 2010; 35: 897901.
Studies have also suggested an improvement in safety attitudes:

Kawano T, et al. Improvement of teamwork and safety climate

following implementation of the WHO surgical safety checklist
at a university hospital in Japan. J Anesth 2013. doi:
10.1007/s00540-013-1737-y.

Haynes AB, Weiser TG, Berry WR, et al. Changes in safety

attitude and relationship to decreased postoperative morbidity
and mortality following implementation of a checklist-based
surgical safety intervention. BMJ Quality & Safety 2011; 20:
1027

Why does the Checklist work?

There are several theories as to why the Checklist has been

able to produce the results it has. The original study suggests
that it is multifactorial, and that improvement could be
because of the checklist itself, the formal pauses, the resultant
push for uptake of technology, and improved teamwork and
communication. We know that it is not as effective at reducing
morbidity and mortality when only partially completed, so it is
not just one component that is driving the results.
Does the Checklist apply to all low- and middle-income countries?

Four low-income countries contributed to the original WHO

study. Adapted appropriately, the Checklist can be an effective
tool in these settings when adoptedd as part of a wider push
for improvement in patient safety culture. WHO acknowledges
that implementation of its Checklist needs to be well
considered; limited availability of resources and less structure
around patient safety provides a different context for effective
use. Further research needs to be undertaken to better
understand what, if any, modications need to be made to the
Checklist for use in low- and middle-income countries (LMICs).
My hospital is quite large with many operating rooms. How can I
implement a checklist in this environment?

The key to successful implementation is to start small. Start

with a single operating room on one day and see how it works.
This will guide you to strategies for altering the checklist to t
your needs, as well as identify potential barriers to its
successful
adaptation.
We already do these things. Why should we use a checklist?

While most or all of the items on the WHO Checklist may

already be done at your hospital, we have found that in most
hospitals there are opportunities for improvement in
consistency. The checklist helps ensure that important safety

steps

are

followed

for

each

and

every

operation.

Our surgical teams dont want to use the WHO Surgical Safety Checklist
unless they can change a few of the elements. Is it okay to make changes
to the Checklist?

Yes, the Checklist was not intended to be comprehensive, and

we encourage modications for local use. We understand that
the Checklist, while intended to be universally applicable, is
not always a perfect t for all institutions. Modications can be
made to include items that are deemed essential. However,
please avoid making the Checklist too comprehensive.

The more items added to it, the more difcult it will be to

successfully implement. Please refer to the Checklist
Adaptation Guide, before making any changes, for
recommendations
on
modifying
the
Checklist.

Who should be in charge of running the Checklist?

Although every member of the operating team surgeons,

anaesthetists, nurses, technicians and other operating room
personnel is involved in its execution, a single person should
be responsible for leading the discussion of all components of
the Checklist. This is essential for its success. This will often be
a circulating nurse, but it can be any clinician or health-care
professional participating in the operation. This individual can
and should prevent the team from progressing to the next
phase of the operation until each step has been satisfactorily
addressed.
My team often stays together for the whole day. Must we introduce
ourselves before every surgery?

The most critical time for introductions is at the beginning of

an operative day. There is no need to repeat introductions if
they have already been made. However, if new members join a
room, they should introduce themselves as should every
member of the team present. Even if everyone knows each
other, introductions are important as they serve to reinforce
team communication (and can help avoid the embarrassment
of having to ask the name of someone with whom one has

been

working

for

long

time!).

Should we memorize the Checklist?

No. Checklists are created to avoid the pitfalls of memorization

and omissions that occur when standardized processes are not
clearly written and dened. The goal of the Checklist is to help
ensure that teams consistently follow a few critical safety steps
and thereby minimize the most common avoidable risks
endangering the lives and well-being of surgical patients.
We are already very busy in the operating room. Isnt this just one more
task using up valuable time?

Once the Checklist has become familiar to operating teams, it

requires very little extra time to perform. Most of the steps are
incorporated into existing workow and the remainder will add
only one or two minutes to the OR time. However, the
Checklist can also save time be ensuring better coordination
between the teams, minimizing slowdowns for tasks like
retrieval
of
additional
equipment.
While there is enthusiasm amongst some clinicians for the Checklist, there
are others who do not see the value of this initiative. Can we still use the
Checklist?

Yes. Implementation should always begin with the most

enthusiastic. Go after the low hanging fruit, namely those
interested in improvement! The Checklist can be implemented
by an individual clinician in cases in which he or she
participates, a selected service or operating room suite at a
hospital, or on a hospital-wide or even system-wide basis.
Focus energy on those areas and individuals who are receptive
to the idea at rst and as they become accustomed to the
Checklist and its benets, they will help spread it to their
peers.
I have additional questions not covered by the FAQ. Can I speak to
someone?

Please contact patientsafety@who.int.