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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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Self-citationFive Steps to Develop Checklists for Evaluating Clinical Performance
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Plews-Ogan, M., May, N., Owens, J. E., Ardelt, M., Shapiro, J., & Bell, S. K. (2015) · Academic Medicine · doi:10.1097/acm.0000000000000886 · Cited by 98
2011 ACCF/AHA Guideline for Coronary Artery Bypass Graft Surgery: Executive Summary
Hillis, L. D., Smith, P. K., Anderson, J. L., Bittl, J. A., Bridges, C. R., Byrne, J. G., Cigarroa, J. E., DiSesa, V. J., Hiratzka, L. F., Hutter, A. M., et al. (2011) · Journal of the American College of Cardiology · doi:10.1016/j.jacc.2011.08.008 · Cited by 98
Surgical checklists: the human factor
O'Connor, P. E., Reddin, C., O’Sullivan, M., O'Duffy, F., & Keogh, I. J. (2013) · Patient Safety in Surgery · doi:10.1186/1754-9493-7-14 · Cited by 93
“; licensee BioMed Cent Commons Attribution License (http://creativec reproduction in any medium, provided the or with the goal of reducing the rate of major surgical complications [5].”
BackgroundResultTrend analysis of radiation therapy incidents over seven years
Bissonnette, J., & Medlam, G. (2010) · Radiotherapy and Oncology · doi:10.1016/j.radonc.2010.05.002 · Cited by 92
“The application of quality tools to the health care industry may lead to further reduction in incident rates, as has been demonstrated in surgery [30] and in other industries [31].”
BackgroundProcess Management for Knowledge Work
Davenport, T. H. (2010) · Springer eBooks · doi:10.1007/978-3-642-00416-2_2 · Cited by 91
A Checklist-Based Intervention to Improve Surgical Outcomes in Michigan
Reames, B. N., Krell, R. W., Campbell, D. A., & Dimick, J. B. (2015) · JAMA Surgery · doi:10.1001/jamasurg.2014.2873 · Cited by 91
Panesar, S. S., Noble, D. J., Mirza, S. B., Patel, B. H., Mann, B., Emerton, M. E., Cleary, K., Sheikh, A., & Bhandari, M. (2011) · Journal of Orthopaedic Surgery and Research · doi:10.1186/1749-799x-6-18 · Cited by 90
Malinoski, D., Daly, M. C., Patel, M. S., Oley-Graybill, C., Foster, C. E., & Salim, A. (2011) · The Journal of Trauma: Injury, Infection, and Critical Care · doi:10.1097/ta.0b013e31822779e5 · Cited by 90
Leaper, D. J., McBain, A. J., Krämer, A., Assadian, O., Sánchez, J. L. A., Lumio, J., & Kiernan, M. A. (2010) · Annals of The Royal College of Surgeons of England · doi:10.1308/003588410x12699663905276 · Cited by 90
Rose, J., Chang, D. C., Weiser, T. G., Kassebaum, N. J., & Bickler, S. W. (2014) · PLoS ONE · doi:10.1371/journal.pone.0089693 · Cited by 91
“[25–29].”
Self-citationAccurate Classification of Difficult Intubation by Computerized Facial Analysis
Connor, C. W., & Segal, S. (2010) · Anesthesia & Analgesia · doi:10.1213/ane.0b013e31820098d6 · Cited by 89
“It has been incorporated into the difficult airway algorithm of not only the American Society of Anesthesiologists 7 and those of several other countries, 20 but also most recently into the World Health Organization Surgical Safety Checklist, 21 the use of which is being encouraged in every operating room in the world.”
BackgroundEmergency, anaesthetic and essential surgical capacity in the Gambia
Iddriss, A., Shivute, N., Bickler, S. W., Cole-Ceesay, R., Jargo, B., Abdullah, F., & Cherian, M. N. (2011) · Bulletin of the World Health Organization · doi:10.2471/blt.11.086892 · Cited by 89
Moliner, J., Honoré, P. M., Riera, J. A. S.-I., Gutiérrez, M. H., & Spapen, H. D. (2012) · Blood Purification · doi:10.1159/000342064 · Cited by 89
Lin, E., Powell, D. K., & Kagetsu, N. J. (2014) · Journal of Imaging Informatics in Medicine · doi:10.1007/s10278-014-9703-2 · Cited by 89
Patient Safety in Interventional Radiology: A CIRSE IR Checklist
Lee, M. J., Fanelli, F., Haage, P., Hausegger, K., & van Lienden, K. P. (2011) · CardioVascular and Interventional Radiology · doi:10.1007/s00270-011-0289-5 · Cited by 88
It is time to talk about people: a human-centered healthcare system
Searl, M. M., Borgi, L., & Chemali, Z. N. (2010) · Health Research Policy and Systems · doi:10.1186/1478-4505-8-35 · Cited by 89
“Safety-oriented analyses and solutions have been at the forefront of user-centered applications in healthcare, with such examples as bar-code technology [64] and checklists [65].”
BackgroundFrcp, C. G., & de Silva, J. (2013) · Cited by 89
Triage of high-risk surgical patients for intensive care
Sobol, J. B., & Wunsch, H. (2011) · Critical Care · doi:10.1186/cc9999 · Cited by 87
Reducing the Burden of Surgical Harm
Howell, A.-M., Panesar, S. S., Burns, E. M., Donaldson, L., & Darzi, A. W. (2013) · Annals of Surgery · doi:10.1097/sla.0000000000000371 · Cited by 91
Consensus opinion on MRI simulation for external beam radiation treatment planning
Paulson, E. S., Crijns, S. P. M., Keller, B. M., Wang, J., Schmidt, M. A., Coutts, G. A., & van der Heide, U. A. (2016) · Radiotherapy and Oncology · doi:10.1016/j.radonc.2016.09.018 · Cited by 87
Munday, G. S., Deveaux, P. G., Roberts, H., Fry, D. E., & Polk, H. C. (2014) · The American Journal of Surgery · doi:10.1016/j.amjsurg.2014.05.005 · Cited by 86
“This study illustrated that poorly performing hospitals could see a marked decrease in SSI% (54%) with the orderly administration of prophylactic antibiotics.(29) Perhaps the most dramatic outcome of our study is how very seldom ‘‘before and after’’ results are provided for the reader.”
BackgroundStandardizing Postoperative PICU Handovers Improves Handover Metrics and Patient Outcomes
Breuer, R. K., Taicher, B. M., Turner, D. A., Cheifetz, I. M., & Rehder, K. J. (2015) · Pediatric Critical Care Medicine · doi:10.1097/pcc.0000000000000343 · Cited by 87
Green, B., Parry, D., Oeppen, R. S., Plint, S., Dale, T., & Brennan, P. A. (2016) · Oral Diseases · doi:10.1111/odi.12547 · Cited by 93
Surgical complications following malignant brain tumor surgery: An analysis of 2002–2011 data
Ramos, R. D. L. G., Kerezoudis, P., Tamargo, R. J., Brem, H., Huang, J., & Bydon, M. (2015) · Clinical Neurology and Neurosurgery · doi:10.1016/j.clineuro.2015.11.005 · Cited by 86
“Of note, the less than 10 cases of wrong-side surgery in the present study occurred prior to the year 2008, when the surgical safety checklist was implemented [17].”
ResultSeward, N., Hanlon, C., Abdulahi, A., Abrams, Z., Alem, A., Araya, R., Bachmann, M., Bogale, B., Brima, N., Chibanda, D., et al. (2021) · doi:10.1101/2021.01.06.20248468 · Cited by 84
“WHO surgical checklist.(66) The WHO Surgical Safety Checklist was developed to decrease errors and adverse events and increase teamwork and communication in surgery.”
MethodPatient autonomy–centered self-care checklist reduces hospital readmissions after ileostomy creation
Hardiman, K. M., Reames, C. D., McLeod, M. C., & Regenbogen, S. E. (2016) · Surgery · doi:10.1016/j.surg.2016.05.007 · Cited by 85
Sotto, K. T., Burian, B. K., & Brindle, M. E. (2021) · Journal of the American College of Surgeons · doi:10.1016/j.jamcollsurg.2021.08.692 · Cited by 85
Böhmer, A. B., Wappler, F., Tinschmann, T., KINDERMANN, P., Rixen, D., BELLENDIR, M., SCHWANKE, U., Bouillon, B., & Gerbershagen, M. U. (2011) · Acta Anaesthesiologica Scandinavica · doi:10.1111/j.1399-6576.2011.02590.x · Cited by 85
Dedy, N. J., Bonrath, E. M., Zevin, B., & Grantcharov, T. (2013) · Surgery · doi:10.1016/j.surg.2013.04.034 · Cited by 85
“Large-scale initiatives have shown significant effects of surgical safety checklists and preoperative briefings on patient safety(70) and perioperative morbidity and mortality.(71,72) Patient safety and error management, including tools such as briefings and checklists, constitute elements of Crew Resource Management…”
BackgroundSafety considerations for IMRT: Executive summary
Moran, J. M., Dempsey, M. C., Eisbruch, A., Fraass, B. A., Galvin, J. M., Ibbott, G. S., & Marks, L. B. (2011) · Medical Physics · doi:10.1118/1.3600524 · Cited by 85
Collins, S. J., Newhouse, R. P., Porter, J., & Talsma, A. (2014) · AORN Journal · doi:10.1016/j.aorn.2013.07.024 · Cited by 85
“This change in reimbursement policy was driven by data indicating that 48% of all surgical complications are preventable.(7,8) Surgical safety also is an international focus.”
BackgroundMethodInfluentialde Jager, E. C., McKenna, C., Bartlett, L., Gunnarsson, R. K., & Ho, Y. (2016) · World Journal of Surgery · doi:10.1007/s00268-016-3519-9 · Cited by 85
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
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