A surgical safety checklist to reduce morbidity and mortality in a global population
Open accessAbstract
BACKGROUND: Surgery has become an integral part of global health care, with an estimated 234 million operations performed yearly. Surgical complications are common and often preventable. We hypothesized that a program to implement a 19-item surgical safety checklist designed to improve team communication and consistency of care would reduce complications and deaths associated with surgery. METHODS: Between October 2007 and September 2008, eight hospitals in eight cities (Toronto, Canada; New Delhi, India; Amman, Jordan; Auckland, New Zealand; Manila, Philippines; Ifakara, Tanzania; London, England; and Seattle, WA) representing a variety of economic circumstances and diverse populations of patients participated in the World Health Organization's Safe Surgery Saves Lives program. We prospectively collected data on clinical processes and outcomes from 3733 consecutively enrolled patients 16 years of age or older who were undergoing noncardiac surgery. We subsequently collected data on 3955 consecutively enrolled patients after the introduction of the Surgical Safety Checklist. The primary end point was the rate of complications, including death, during hospitalization within the first 30 days after the operation. RESULTS: The rate of death was 1.5% before the checklist was introduced and declined to 0.8% afterward (P=0.003). Inpatient complications occurred in 11.0% of patients at baseline and in 7.0% after introduction of the checklist (P<0.001). CONCLUSIONS: Implementation of the checklist was associated with concomitant reductions in the rates of death and complications among patients at least 16 years of age who were undergoing noncardiac surgery in a diverse group of hospitals.
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Numerous successful patient-safety interventions have used a bundled approach.
“We chose to combine several educational and process changes into a single bundled intervention because numerous successful patient-safety interventions have used this approach.1,2,40”
From Changes in medical errors after implementation of a handoff program (2014) · cites this paper as [2]
Routine use of surgical safety checklists can reduce perioperative complications.
“The routine use of surgical safety checklists can reduce perioperative complications.”
From Society for Maternal-Fetal Medicine Special Statement: Surgical safety checklists for cesarean delivery (2021) · cites this paper as [3]
Surgical safety checklists have been shown to reduce serious perioperative complications and death by 30% to 40% when implemented across a wide range of hospital settings.
“Surgical safety checklists, such as the one developed by the World Health Organization (WHO), 2 have been shown to reduce serious perioperative complications and death by 30% to 40% when implemented across a wide range of hospital settings.3,4”
From Society for Maternal-Fetal Medicine Special Statement: Surgical safety checklists for cesarean delivery (2021) · cites this paper as [3]
Studies demonstrating reduced morbidity and mortality with the use of a surgical safety checklist include detailed implementation programs involving extensive staff engagement and education.
“Studies demonstrating reduced morbidity and mortality with the use of a surgical safety checklist include detailed implementation programs involving extensive staff engagement and education.3,4,9”
From Society for Maternal-Fetal Medicine Special Statement: Surgical safety checklists for cesarean delivery (2021) · cites this paper as [3]
This problem may help to explain apparently contradictory findings about the value of surgical checklists.
“This problem may help to explain apparently contradictory findings about the value of surgical checklists, for example.47–49”
From Demystifying theory and its use in improvement (2015) · cites this paper as [47]
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Donaldson, L., Kelley, E., Dhingra‐Kumar, N., Kiény, M.-P., & Sheikh, A. (2017) · The Lancet · doi:10.1016/s0140-6736(17)31047-4 · Cited by 595 · see citing works
Prevention of Intraoperative Awareness in a High-Risk Surgical Population
Avidan, M. S., Jacobsohn, E., Glick, D. B., Burnside, B. A., Zhang, L., Villafranca, A., Karl, L. R., Kamal, S., Torres, B. A., O'Connor, M., et al. (2011) · New England Journal of Medicine · doi:10.1056/nejmoa1100403 · Cited by 581 · see citing works
Simulation-Based Trial of Surgical-Crisis Checklists
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“Surgical technologist 9 (13) 0 56 44 0 0 0”
Self-citationSurgical checklists: a systematic review of impacts and implementation
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Surgical Site Infection Prevention
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“have been reported elsewhere, as have the specifics of the checklist-based implementation programme.(7)”
BackgroundMethodInfluentialSelf-citationWeissman, D. E., & Meier, D. E. (2010) · Journal of Palliative Medicine · doi:10.1089/jpm.2010.0347 · Cited by 512 · see citing works
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“For instance, when ‘‘the care bundle’’ is implemented as rapidly as possible, it improves the management of outof-hospital respiratory distress [15], sedation and weaning from the ventilator [16, 17], as well as severe sepsis [18, 19] and surgical procedures [20].”
BackgroundDifficult Airway Society guidelines for awake tracheal intubation (ATI) in adults
Ahmad, I., El‐Boghdadly, K., Bhagrath, R., Hodzovic, I., McNarry, A. F., Mir, F., O'Sullivan, E. P., Patel, A., Stacey, M., & Vaughan, D. (2020) · Anaesthesia · doi:10.1111/anae.14904 · Cited by 563 · see citing works
Transforming healthcare: a safety imperative
Leape, L. L., Berwick, D. M., Clancy, C. M., Conway, J., Gluck, P., Guest, J., Lawrence, D., Morath, J. M., O’Leary, D. S., O’Neill, P., et al. (2009) · BMJ Quality & Safety · doi:10.1136/qshc.2009.036954 · Cited by 486 · see citing works
Weiser, T. G., Haynes, A. B., Dziekan, G., Berry, W. R., Lipsitz, S. R., & Gawande, A. A. (2010) · Annals of Surgery · doi:10.1097/sla.0b013e3181d970e3 · Cited by 468 · see citing works
“Implementation of the World Health Organization’s 19-item Surgical Safety Checklist improved the process of care and was associated with a one-third decrease in complications across all types of noncardiac adult surgery.(1) In situations requiring urgent intervention, however, there has been worry that use of a checkl…”
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“1136/bmjopen-2018-028280 Open access performance measures are surgical complications, mortality or morbidity.(67) In anaesthesia, studies often use expert ratings based on checklists to assess the provision of anaesthesia.”
BackgroundHospital Volume and Operative Mortality in the Modern Era
Reames, B. N., Ghaferi, A. A., Birkmeyer, J. D., & Dimick, J. B. (2013) · Annals of Surgery · doi:10.1097/sla.0000000000000375 · Cited by 446 · see citing works
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Effects of the Introduction of the WHO “Surgical Safety Checklist” on In-Hospital Mortality
van Klei, W. A., Hoff, R. G., van Aarnhem, E. E. H. L., Simmermacher, R. K. J., Regli, L., Kappen, T. H., van Wolfswinkel, L., Kalkman, C. J., Bühre, W., & Peelen, L. M. (2011) · Annals of Surgery · doi:10.1097/sla.0b013e31823779ae · Cited by 429 · see citing works
The Safety of Inpatient Health Care
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Self-citation2014 ESC/ESA Guidelines on non-cardiac surgery
Kristensen, S. D., Knuuti, J. M., Saraste, A., Anker, S. D., Bøtker, H. E., Hert, S. G. D., Ford, I., González‐Juanatey, J. R., Görenek, B., Heyndrickx, G. R., et al. (2014) · European Journal of Anaesthesiology · doi:10.1097/eja.0000000000000150 · Cited by 406 · see citing works
Patient Safety At Ten: Unmistakable Progress, Troubling Gaps
Wachter, R. M. (2009) · Health Affairs · doi:10.1377/hlthaff.2009.0785 · Cited by 401 · see citing works
Bergs, J., Hellings, J., Cleemput, I., Zurel, O., Troyer, V. D., Hiel, M. V., Demeere, J. L., Claeys, D. A. B., & Vandijck, D. M. (2014) · British journal of surgery · doi:10.1002/bjs.9381 · Cited by 391 · see citing works
The Helsinki Declaration on Patient Safety in Anaesthesiology
Mellin‐Olsen, J., Staender, S. E. A., Whitaker, D., & Smith, A. F. (2010) · European Journal of Anaesthesiology · doi:10.1097/eja.0b013e32833b1adf · Cited by 387 · see citing works
Technologies for global health
Howitt, P. J., Darzi, A. W., Yang, G., Ashrafian, H., Atun, R. A., Barlow, J. G., Blakemore, A. I. F., Bull, A. M. J., Car, J., Conteh, L., et al. (2012) · The Lancet · doi:10.1016/s0140-6736(12)61127-1 · Cited by 384 · see citing works
Pre-operative evaluation of adults undergoing elective noncardiac surgery
Hert, S. G. D., Staender, S. E. A., Fritsch, G., Hinkelbein, J., Afshari, A., Bettelli, G., Böck, M., Chew, M. S., Coburn, M., ROBERTIS, E. D., et al. (2018) · European Journal of Anaesthesiology · doi:10.1097/eja.0000000000000817 · Cited by 388 · see citing works
Handbook on Business Process Management 1
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An open letter toThe BMJeditors on qualitative research
Greenhalgh, T., Annandale, E. C., Ashcroft, R. E., Barlow, J. G., Black, N. A., Bleakley, A., Boaden, R., Braithwaite, J., Britten, N., Carnevale, F. A., et al. (2016) · BMJ · doi:10.1136/bmj.i563 · Cited by 378 · see citing works
Rao, L., Wu, L., Liu, Z., Tian, R., Yu, G., Zhou, Z., Yang, K., Xiong, H., Zhang, A., Yu, G.-T., et al. (2020) · Nature Communications · doi:10.1038/s41467-020-18626-y · Cited by 379 · see citing works
Effective surgical safety checklist implementation
Conley, D. M., Singer, S. J., Edmondson, L., Berry, W. R., & Gawande, A. A. (2011) · Journal of the American College of Surgeons · doi:10.1016/j.jamcollsurg.2011.01.052 · Cited by 372 · see citing works
“g In 2009, investigators documented a significant reduction in mortality and other postoperative complications with use of the WHO surgical safety checklist.(1) Since then, the checklist has been adopted by more than 3,900 hospitals in 122 countries, representing more than 90% of the world’s population.”
MethodSelf-citationStrategies to Prevent Surgical Site Infections in Acute Care Hospitals: 2014 Update
Anderson, D. J., Podgorny, K., Berríos-Torres, S. I., Bratzler, D. W., Dellinger, E. P., Greene, L. R., Nyquist, A., Saiman, L. M., Yokoe, D. S., Maragakis, L. L., et al. (2014) · Infection Control and Hospital Epidemiology · doi:10.1017/s0899823x00193869 · Cited by 371 · see citing works
Self-citationChecklists to Reduce Diagnostic Errors
Ely, J. W., Graber, M. L., & Croskerry, P. (2011) · Academic Medicine · doi:10.1097/acm.0b013e31820824cd · Cited by 366 · see citing works
Interprofessional Teamwork for Health and Social Care
Reeves, S., Lewin, S., Espin, S., & Zwarenstein, M. (2010) · Wiley eBooks · doi:10.1002/9781444325027 · Cited by 840 · see citing works
Leape, L. L., Shore, M. F., Dienstag, J. L., Mayer, R. J., Edgman‐Levitan, S., Meyer, G. S., & Healy, G. B. (2012) · Academic Medicine · doi:10.1097/acm.0b013e318258338d · Cited by 359 · see citing works
“44,45 If the physician is not a constructive team player, team efforts fail, and patients suffer the consequences.”
Procter, L., Davenport, D. L., Bernard, A. C., & Zwischenberger, J. B. (2009) · Journal of the American College of Surgeons · doi:10.1016/j.jamcollsurg.2009.09.034 · Cited by 351 · see citing works
Essential surgery: key messages from Disease Control Priorities, 3rd edition
Mock, C., Donkor, P., Gawande, A. A., Jamison, D. T. T., Kruk, M. E., & Debas, H. T. (2015) · The Lancet · doi:10.1016/s0140-6736(15)60091-5 · Cited by 338 · see citing works
Self-citationThe Checklist Manifesto. How to get things right
Newbold, D. (2010) · Journal of Nursing Management · doi:10.1111/j.1365-2834.2010.01123.x · Cited by 338 · see citing works
Starmer, A. J., Sectish, T. C., Simon, D. W., Keohane, C., McSweeney, M. E., Chung, E. Y., Yoon, C. S., Lipsitz, S. R., Wassner, A. J., Harper, M. B., et al. (2013) · JAMA · doi:10.1001/jama.2013.281961 · Cited by 337 · see citing works
Self-citationCognitive debiasing 2: impediments to and strategies for change
Croskerry, P., Singhal, G., & Mamede, S. (2013) · BMJ Quality & Safety · doi:10.1136/bmjqs-2012-001713 · Cited by 419 · see citing works
“…▸ The implementation of a surgical safety checklist led to reductions in death rates and complications in non-cardiac surgery in a multicenter study 62 Stopping rules Stopping rules are an important form of forcing functions — they determine when enough information has been gathered to make an…”
BackgroundBalancing “No Blame” with Accountability in Patient Safety
Wachter, R. M., & Pronovost, P. J. (2009) · New England Journal of Medicine · doi:10.1056/nejmsb0903885 · Cited by 335 · see citing works
Cognitive bias in clinical medicine
O'Sullivan, E., & Schofield, S. (2018) · Journal of the Royal College of Physicians of Edinburgh · doi:10.4997/jrcpe.2018.306 · Cited by 334 · see citing works
Do Safety Checklists Improve Teamwork and Communication in the Operating Room? A Systematic Review
Russ, S., Rout, S., Sevdalis, N., Moorthy, K., Darzi, A. W., & Vincent, C. A. (2013) · Annals of Surgery · doi:10.1097/sla.0000000000000206 · Cited by 332 · see citing works
Self-citationPatient Safety in the Cardiac Operating Room: Human Factors and Teamwork
Wahr, J. A., Prager, R. L., Abernathy, J. H., Martinez, E. A., Salas, E., Seifert, P. C., Groom, R. C., Spiess, B. D., Searles, B. E., Sundt, T. M., et al. (2013) · Circulation · doi:10.1161/cir.0b013e3182a38efa · Cited by 331 · see citing works
The potential of artificial intelligence to improve patient safety: a scoping review
Bates, D. W., Levine, D. M., Syrowatka, A., Kuznetsova, M., Craig, K. J. T., Rui, A., Jackson, G. P., & Rhee, K. B. L. (2021) · npj Digital Medicine · doi:10.1038/s41746-021-00423-6 · Cited by 329 · see citing works
Learning Through Noticing: Theory and Evidence from a Field Experiment *
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“For example, Haynes et al. (2009) find that introducing a 19-item surgical safety checklist in eight hospitals reduced the rate of death in the 30 days following noncardiac surgery from 1.5% before the checklist was introduced to 0.8% afterward, and more general inpatient complications from 33.”
BackgroundInfluentialStrategies to prevent surgical site infections in acute-care hospitals: 2022 Update
Calderwood, M. S., Anderson, D. J., Bratzler, D. W., Dellinger, E. P., Garcia‐Houchins, S., Maragakis, L. L., Nyquist, A., Perkins, K. M., Preas, M. A., Saiman, L. M., et al. (2023) · Infection Control and Hospital Epidemiology · doi:10.1017/ice.2023.67 · Cited by 328 · see citing works
Self-citationPractical challenges of introducing WHO surgical checklist: UK pilot experience
Vats, A., Vincent, C. A., Nagpal, K., Davies, R., Darzi, A. W., & Moorthy, K. (2010) · BMJ · doi:10.1136/bmj.b5433 · Cited by 323 · see citing works
Self-citationBarriers to staff adoption of a surgical safety checklist
Fourcade, A., Blache, J. L., Grenier, C., Bourgain, J. L., & Minvielle, É. (2011) · BMJ Quality & Safety · doi:10.1136/bmjqs-2011-000094 · Cited by 323 · see citing works
Schwendimann, R., Blatter, C., Dhaini, S., Simon, M., & Ausserhofer, D. (2018) · BMC Health Services Research · doi:10.1186/s12913-018-3335-z · Cited by 423 · see citing works
How to study improvement interventions: a brief overview of possible study types
Portela, M. C., Pronovost, P. J., Woodcock, T. M., Carter, P., & Dixon‐Woods, M. (2015) · BMJ Quality & Safety · doi:10.1136/bmjqs-2014-003620 · Cited by 318 · see citing works
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How safe is primary care? A systematic review
Panesar, S. S., deSilva, D., Carson‐Stevens, A., Cresswell, K. M., Salvilla, S., Slight, S. P., Javad, S., Netuveli, G., Larizgoitia, I., Donaldson, L., et al. (2015) · BMJ Quality & Safety · doi:10.1136/bmjqs-2015-004178 · Cited by 312 · see citing works
Cannesson, M. P., Pestel, G., Ricks, C., Hoeft, A., & Perel, A. (2011) · Critical Care · doi:10.1186/cc10364 · Cited by 310 · see citing works
“Recent and most important advances in anesthesia and critical care have been provided by “check list” implementations [32,33].”
BackgroundKestle, J. R. W., Riva-Cambrin, J. K., Wellons, J. C., Kulkarni, A. V., Whitehead, W. E., Walker, M. L., Oakes, W. J., Drake, J. M., Luerssen, T. G., Simon, T. D., et al. (2011) · Journal of Neurosurgery Pediatrics · doi:10.3171/2011.4.peds10551 · Cited by 309 · see citing works
Serious H azards of T ransfusion (SHOT) haemovigilance and progress is improving transfusion safety
Bolton‐Maggs, P. H. B., & Cohen, H. (2013) · British Journal of Haematology · doi:10.1111/bjh.12547 · Cited by 306 · see citing works
“SHOT has recommended the introduction of a transfusion checklist because this has proved effective in reducing errors in surgery (Haynes et al, 2009; Bolton-Maggs & Cohen, 2012).”
MethodImplicit bias in healthcare: clinical practice, research and decision making
Gopal, D. P., Chetty, U., O'Donnell, P., Gajria, C., & Blackadder-Weinstein, J. (2021) · Future Healthcare Journal · doi:10.7861/fhj.2020-0233 · Cited by 298 · see citing works
A scoping review to improve conceptual clarity of interprofessional interventions
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“For example, Haynes et al. (2009) reported on the effectiveness of a surgical safety checklist.”
BackgroundResultDimick, J. B., Ruhter, J., Vaughan‐Sarrazin, M., & Birkmeyer, J. D. (2013) · Health Affairs · doi:10.1377/hlthaff.2011.1365 · Cited by 306 · see citing works
Schweizer, M. L., Chiang, H., Septimus, E. J., Moody, J. A., Braun, B. I., Hafner, J. M., Ward, M., Hickok, J. D., Perencevich, E. N., Diekema, D. J., et al. (2015) · JAMA · doi:10.1001/jama.2015.5387 · Cited by 303 · see citing works
“7 days [2-44]) and within 1 day after the operations (median [range], 0.”
BackgroundShare, D. A., Campbell, D. A., Birkmeyer, N. J. O., Prager, R. L., Gurm, H. S., Moscucci, M. M., Udow‐Phillips, M., & Birkmeyer, J. D. (2011) · Health Affairs · doi:10.1377/hlthaff.2010.0526 · Cited by 301 · see citing works
Recommendations for the intra-hospital transport of critically ill patients
Fanara, B., Manzon, C., Barbot, O., Desmettre, T., & Capellier, G. (2010) · Critical Care · doi:10.1186/cc9018 · Cited by 300 · see citing works
- Authors
- Haynes, A. B., Weiser, T. G., Berry, W. R., Lipsitz, S. R., Breizat, A.-H. S., Dellinger, E. P., Herbosa, T., Joseph, S., Kibatala, P. L., Lapitan, M. C. M., Merry, A. F., Moorthy, K., Reznick, R. K., Taylor, B., & Gawande, A. A.
- Affiliations
- Harvard University (US)
- Brigham and Women's Hospital (US)
- Ministry of Health (JO)
- University of Washington (US)
- University of the Philippines Manila (PH)
- St. Stephen’s Hospital (IN)
- St. Francis Referral Hospital (TZ)
- University of Auckland (NZ)
- National Health Service (GB)
- University Health Network (CA)
- ORCID
- Venue
- New England Journal of Medicine
- Publisher
- Massachusetts Medical Society
- Published
- 2009-01-29
- Volume
- 360
- Issue
- 5
- Pages
- 491-499
- ISSN
- 0028-4793 (ISSN-L)
- 1533-4406
- OpenAlex
- W2119472226
- Cited by
- 5,688
- References
- 41
- Citations by year
- 2026: 256 · 2025: 215 · 2024: 256 · 2023: 247 · 2022: 325 · 2021: 335 · 2020: 337 · 2019: 336 · 2018: 340 · 2017: 362 · 2016: 349 · 2015: 406 · 2014: 405 · 2013: 372 · 2012: 363
- FWCI
- 514.06
- Type
- journal article
- Language
- en
- Open access
- bronze
- doi.org
- Locations
- New England Journal of Medicine (publishedVersion)
- PubMed (publishedVersion)
- Digital Access to Scholarship at Harvard (DASH) (Harvard University) (submittedVersion, cc-by)
- ResearchSpace (University of Auckland) (submittedVersion)
- Topics
- Health Sciences › Health Professions › Emergency Medical Services › Patient Safety and Medication Errors
- Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Cardiac, Anesthesia and Surgical Outcomes
- Health Sciences › Medicine › Surgery › Surgical site infection prevention
- Keywords
- surgical safety checklist, surgical complications, postoperative mortality, non-cardiac surgery, team communication, patient safety, checklist implementation, global health care, in-hospital complications
- MeSH terms
- Humans, Outcome and Process Assessment, Health Care, Postoperative Complications, Prospective Studies, Surgical Procedures, Operative, Safety Management
About these checks
Registry, retraction, Cites and statistics results are computed, not judged, with one exception: a printed reference that no index lists is read once by a model before it counts as a citation error. Claims are extracted by a model and kept only when their quote appears verbatim in the text; each cited source is then checked, with a model’s help, for whether it says what the claim relies on. Those verdicts can be wrong — read the claim’s quote and the cited source before relying on one.
Statistics and arithmetic are recomputed, not judged.
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