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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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“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]
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“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]
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“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]
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“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]
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“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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“Other studies mentioned completion scores that are self-reported by hospitals, which appear to be much higher than real-life completion [22,25] or do not present completion rates at all [12,24].”
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“Overall, 3%–17% of all surgeries result in major complications; approximately 50% of which are considered preventable [2,3].”
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ResultAspiration during anaesthesia in the first 4000 incidents reported to webAIRS
Kluger, M. T., Culwick, M. D., Moore, M. R., & Merry, A. (2019) · Anaesthesia and Intensive Care · doi:10.1177/0310057x19854456 · Cited by 35
Self-citationVariability in Pediatric Brain Death Determination Protocols in the United States
Francoeur, C., Weiss, M. J., Macdonald, J. M., Press, C. A., Greer, D. M., Berg, R. A., Topjian, A., Morrison, W. E., & Kirschen, M. P. (2021) · Neurology · doi:10.1212/wnl.0000000000012225 · Cited by 35
Goldhaber-Fiebert, S. N., Lei, V., Nandagopal, K., & Merrell, S. B. (2015) · The Joint Commission Journal on Quality and Patient Safety · doi:10.1016/s1553-7250(15)41028-1 · Cited by 35
Importance of non-technical skills in anaesthesia education
Radhakrishnan, B., Katikar, M. D., Myatra, S. N., Gautam, P. L., Vinayagam, S., & Saroa, R. (2022) · Indian Journal of Anaesthesia · doi:10.4103/ija.ija_1097_21 · Cited by 35
The WHO Surgical Safety Checklist: The Evidence
Wilson, I. H., & WALKER, I. A. (2009) · Journal of Perioperative Practice · doi:10.1177/175045890901901002 · Cited by 35
“The WHO checklist has been piloted in a study involving around 8000 patients in eight hospitals in different parts of the world and has been shown to reduce mortality, serious morbidity and reoperation rates (Haynes et al 2009).”
Customisation of an instrument to assess anaesthesiologists' non-technical skills
Jepsen, R. M. H. G., Spanager, L., Lyk–Jensen, H. T., Dieckmann, P., & Østergaard, D. (2015) · International Journal of Medical Education · doi:10.5116/ijme.54be.8f08 · Cited by 35
“A focus on patient safety in the OR, such as the WHO checklist, also highlighted the importance of teamwork.(25) The interview participants stated that all members of the Danish OR team could likely demand justification and information on actions and further plans from the anaesthesiologist, which might reflect the co…”
BackgroundThe Extended Surgical Time-Out: Does It Improve Quality and Prevent Wrong-Site Surgery?
Lee, S. L. (2010) · The Permanente Journal · doi:10.7812/tpp/10.997 · Cited by 35
The WHO surgical safety checklist: survey of patients’ views
Russ, S., Rout, S., Caris, J. A., Moorthy, K., Mayer, E. K., Darzi, A. W., Sevdalis, N., & Vincent, C. A. (2014) · BMJ Quality & Safety · doi:10.1136/bmjqs-2013-002772 · Cited by 35
Self-citationLacassie, H. J., Ferdinand, C., Guzmán, S., Camus, L., & Echevarría, G. C. (2016) · Medicine · doi:10.1097/md.0000000000003844 · Cited by 35
“In the seminal study by Haynes et al,[3] they incorporated 8 hospitals from every continent, except from Latin America.”
BackgroundInfluentialShafi, S., Collinsworth, A. W., Richter, K. M., Alam, H. B., Becker, L. B., Bullock, M. R., Ecklund, J. M., Gallagher, J. J., Gandhi, R. K., Haut, E. R., et al. (2016) · The Journal of Trauma: Injury, Infection, and Critical Care · doi:10.1097/ta.0000000000001161 · Cited by 36
Annotation: Developing a national programme for VTE prevention
Roberts, L. N., Durkin, M., & Arya, R. (2017) · British Journal of Haematology · doi:10.1111/bjh.14769 · Cited by 35
Ripley, B. A., Tiffany, D., Lehmann, L. S., & Silverman, S. G. (2015) · Journal of Vascular and Interventional Radiology · doi:10.1016/j.jvir.2015.06.007 · Cited by 35
“For example, the World Health Organization Surgical Safety Checklist improved compliance with standards of care by 65% and decreased surgical mortality rates by 50% (42).”
BackgroundThe surgical safety checklist effects are sustained, and team culture is strengthened
Taylor, B., Slater, A., & Reznick, R. K. (2009) · The Surgeon · doi:10.1016/j.surge.2009.11.012 · Cited by 35
Self-citationExplainable machine learning predictions to help anesthesiologists prevent hypoxemia during surgery
Lundberg, S. M., Nair, B., Vavilala, M. S., Horibe, M., Eisses, M. J., Adams, T., Liston, D. E., Low, D. K.-W., Newman, S.-F., Kim, J., et al. (2017) · doi:10.1101/206540 · Cited by 34
Comparação das taxas de infecção cirúrgica após implantação do checklist de segurança
Prates, C. G., Stadnik, C., Bagatini, A., Caregnato, R. C. A., & de Moura, G. M. S. S. (2018) · Acta Paulista de Enfermagem · doi:10.1590/1982-0194201800018 · Cited by 34
Clinical Guidelines and Standardization of Practice to Improve Outcomes
(2019) · Obstetrics and Gynecology · doi:10.1097/aog.0000000000003454 · Cited by 34
“Refinement and sophistication of checklists have shown decreased morbidity and mortality (9).”
BackgroundPerioperative Surgical Care Bundle Reduces Pancreaticoduodenectomy Wound Infections
Lavu, H., Klinge, M. J., Nowcid, L. J., Cohn, H. E., Grenda, D. R., Sauter, P. K., Leiby, B. E., Croker, S. P., Kennedy, E. P., & Yeo, C. J. (2011) · Journal of Surgical Research · doi:10.1016/j.jss.2011.09.028 · Cited by 34
Implementing checklists in the operating room
Low, D. K., WALKER, I. A., & Heitmiller, E. S. (2012) · Pediatric Anesthesia · doi:10.1111/pan.12018 · Cited by 34
Nelson, B. D., Ahn, R., Fehling, M., Eckardt, M. J., Conn, K. L., Elbashir, A. A., Tiernan, M., Purcell, G., & Burke, T. F. (2012) · International Journal of Gynecology & Obstetrics · doi:10.1016/j.ijgo.2012.05.019 · Cited by 34
“The development of the checklists built upon significant recent success of other new checklists and algorithms for resource-limited settings, including presurgical checklists and the Helping Babies Breathe initiative by the American Academy of Pediatrics [22,23].”
BackgroundInfluential“Speaking Up” for Patient Safety in the Pediatric Emergency Department
Eppich, W. (2015) · Clinical Pediatric Emergency Medicine · doi:10.1016/j.cpem.2015.04.010 · Cited by 37
Jain, A. L., Jones, K. C., Simon, J. L., & Patterson, M. (2015) · Patient Safety in Surgery · doi:10.1186/s13037-015-0057-6 · Cited by 34
“However, this improvement in outcomes is heavily dependent on checklist compliance [2,3].”
BackgroundQuality in Orthopaedic Surgery—An International Perspective
Saleh, K. J., Bozic, K. J., Graham, D. B., Shaha, S. H., Swiontkowski, M. F., Wright, J. G., Robinson, B. S., & Novicoff, W. M. (2013) · Journal of Bone and Joint Surgery · doi:10.2106/jbjs.l.00093 · Cited by 34
Factors that drive team participation in surgical safety checks: a prospective study
Gillespie, B., Withers, T., Lavin, J., Gardiner, T. M., & Marshall, A. (2016) · Patient Safety in Surgery · doi:10.1186/s13037-015-0090-5 · Cited by 35
“Since its introduction in over 122 countries, the WHO Surgical Safety Checklist (SSC) has been the focus of many published studies [8–13], including several metaanalyses [14–16], suggesting associated reductions in patient mortality and postoperative complication rates when the SSC is used.”
BackgroundQuality improvement in pediatric surgery
Cameron, D. B., & Rangel, S. J. (2016) · Current Opinion in Pediatrics · doi:10.1097/mop.0000000000000346 · Cited by 34
“[19] demonstrating the efficacy of a surgical checklist in reducing adverse events in the adult surgical popu-”
BackgroundDeaths Following Cholecystectomy and Herniotomy
Nimptsch, U., & Mansky, T. (2015) · Deutsches Ärzteblatt international · doi:10.3238/arztebl.2015.0535 · Cited by 34
Kumar, P. A., Paton, C., & Kirigia, D. G. (2016) · Archives of Disease in Childhood · doi:10.1136/archdischild-2015-308556 · Cited by 36
Surgical Services for Cancer Care
Dare, A. J., Anderson, B. O., Sullivan, R. J., Pramesh, C. S., Yip, C. H., Ilbawi, A., Adewole, I. F., Badwe, R. A., & Gauvreau, C. L. (2015) · World Bank, Washington, DC eBooks · doi:10.1596/978-1-4648-0349-9_ch13 · Cited by 34
Opportunities for system level improvement in antibiotic use across the surgical pathway
Charani, E., Ahmad, R., Tarrant, C., Birgand, G., Leather, A. J. M., Mendelson, M., Moonesinghe, R., Sevdalis, N., Singh, S. K., & Holmes, A. H. (2017) · International Journal of Infectious Diseases · doi:10.1016/j.ijid.2017.04.020 · Cited by 34
Smith, R., & Hofmeyr, R. (2019) · South African Medical Journal · doi:10.7196/samj.2019.v109i3.13633 · Cited by 34
Metadata
- 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 › Medicine › Public Health, Environmental and Occupational Health › 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.
Confidence bands are shown only for fields calibrated on our annotated test set. None is calibrated yet, so no band is shown.
What counts as a claim ›How we measure confidence ›How we check this ›
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