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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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“The original study evaluating the implementation of the World Health Organization SSC demonstrated that its use was associated with significant reductions in postoperative morbidity and mortality in diverse hospital settings.(1) Multiple subsequent studies have also found reductions in postoperative complications(2-5)…”
MethodSelf-citationImpact of Transfusion on Cancer Growth and Outcome
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“We know that some clinical quality interventions are not supported by strong evidence, while uptake and spread of others is poor even where evidence of benefit of the intervention is clear, as in the use of rapid response systems [3,4], checklists [5,6], or interventions to improve hand hygiene [7,8] and central venou…”
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Self-citationEducational program in crisis management for cardiac surgery teams including high realism simulation
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“Efficient debriefing could also motivate teams to do the kind of debriefings after procedures that are encouraged by the World Health Organization’s Surgical Checklist.25 Simulation sessions could also be designed to motivate and teach a process of rebriefing during the procedure, for example, formally or informally r…”
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“These measures have been advocated by surgeons (Bates and Gawande 2003, Haynes et al. 2009, Gawande 2010).”
BackgroundMethodLessons Regarding the Safety of Orthopaedic Patient Care
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Thomas, R., Gupta, R., Griessenauer, C. J., Moore, J. M., Adeeb, N., Motiei-Langroudi, R., Guidal, B., Agarwal, N., Alterman, R. L., Friedlander, R. M., et al. (2017) · World Neurosurgery · doi:10.1016/j.wneu.2017.11.051 · Cited by 74
Education in airway management
Baker, P., Weller, J. M., Greenland, K. B., Riley, R. H., & Merry, A. (2011) · Anaesthesia · doi:10.1111/j.1365-2044.2011.06939.x · Cited by 74
Self-citationAdaptive coordination in surgical teams: an interview study
Bogdanović, J., Perry, J., Guggenheim, M., & Manser, T. (2015) · BMC Health Services Research · doi:10.1186/s12913-015-0792-5 · Cited by 90
“In terms of routine checks, all participants mentioned that they always use the WHO surgical safety checklist [33] before and after every surgical procedure.”
BackgroundMethodSurveillance of surgical site infection: more accurate definitions and intensive recording needed
Leaper, D. J., Tanner, J., & Kiernan, M. A. (2013) · Journal of Hospital Infection · doi:10.1016/j.jhin.2012.11.013 · Cited by 74
“Data on SSIs may be collected for the HPA programme by surveillance-specific staff rather than the whole surgical team (although the process is now almost universally complied with in the World Health Organization’s ‘Safe Surgery Saves Lives Challenge’).(30) This may lead to a lack of ownership from those undertaking…”
BackgroundWrong blood in tube – potential for serious outcomes: can it be prevented?
Bolton‐Maggs, P. H. B., Wood, E. M., & Wiersum‐Osselton, J. C. (2014) · British Journal of Haematology · doi:10.1111/bjh.13137 · Cited by 74
The pursuit of better diagnostic performance: a human factors perspective
Henriksen, K., & Brady, J. (2013) · BMJ Quality & Safety · doi:10.1136/bmjqs-2013-001827 · Cited by 77
What Role Can Process Mining Play in Recurrent Clinical Guidelines Issues? A Position Paper
Gatta, R., Vallati, M., Fernández-Llatas, C., Martínez-Millana, A., Orini, S., Sacchi, L., Lenkowicz, J., Marcos, M., Muñoz-Gama, J., Cuendet, M. A., et al. (2020) · International Journal of Environmental Research and Public Health · doi:10.3390/ijerph17186616 · Cited by 73
“• After their introduction in the practice in 2008 [45], clinical checklists are experiencing a wide spread [46].”
BackgroundBirtcher, K. K., Allen, L. A., Anderson, J. L., Bonaca, M. P., Gluckman, T. J., Hussain, A., Kosiborod, M., Mehta, L. S., & Virani, S. S. (2022) · Journal of the American College of Cardiology · doi:10.1016/j.jacc.2022.08.754 · Cited by 83
The Role of the Nurse and the Preoperative Assessment in Patient Transitions
Malley, A., Kenner, C. A., Kim, T., & Blakeney, B. (2015) · AORN Journal · doi:10.1016/j.aorn.2015.06.004 · Cited by 73
Fighting Surgical Site Infections in Small Animals
Verwilghen, D., & Singh, A. (2014) · Veterinary Clinics of North America Small Animal Practice · doi:10.1016/j.cvsm.2014.11.001 · Cited by 73
Böck, M., Johansson, T., Fritsch, G., Flamm, M., Hansbauer, B., Mann, E., & Sönnichsen, A. C. (2014) · European Journal of Anaesthesiology · doi:10.1097/eja.0000000000000117 · Cited by 73
Kasatpibal, N., Senaratana, W., Chitreecheur, J., Chotirosniramit, N., Pakvipas, P., & Junthasopeepun, P. (2012) · Surgical Infections · doi:10.1089/sur.2011.043 · Cited by 70
“Several studies found that using the checklist has the potential to reduce preventable adverse events in surgery [35–39].”
Chackungal, S., Nickerson, J., Knowlton, L. M., Black, L., Burkle, F. M., Casey, K. B., Crandell, D. M., Demey, D., Giacomo, L. D., Dohlman, L. E., et al. (2011) · Prehospital and Disaster Medicine · doi:10.1017/s1049023x12000064 · Cited by 72
Feedback in surgical education
Boghdady, M. E., & Alijani, A. (2016) · The Surgeon · doi:10.1016/j.surge.2016.06.006 · Cited by 74
Avgerinos, E., & Gokpinar, B. (2016) · Manufacturing & Service Operations Management · doi:10.1287/msom.2016.0597 · Cited by 76
“Our conceptualization of bottleneck-pair could also be viewed with the lens of recent research about the introduction of surgical checklists and their benefits (Haynes et al. 2009, Gawande 2010).”
MethodAdesão ao preenchimento do checklist de segurança cirúrgica
Ribeiro, H. C. T. C., Quites, H. F. D. O., Bredes, A. C., Sousa, K. A. D. S., & Alves, M. (2017) · Cadernos de Saúde Pública · doi:10.1590/0102-311x00046216 · Cited by 72
“Saúde Pública 2017; 33(10):e00046216 tica, neurocirurgia e ortopedia.”
BackgroundInfluentialWilliams, P., Karuppiah, S., Greentree, K., & Darvall, J. N. (2019) · Australian Critical Care · doi:10.1016/j.aucc.2019.02.004 · Cited by 77
Worldwide demand for critical care
Adhikari, N. K. J., & Rubenfeld, G. D. (2011) · Current Opinion in Critical Care · doi:10.1097/mcc.0b013e32834cd39c · Cited by 73
Zargaran, E., Schuurman, N., Nicol, A. J., Matzopoulos, R., Cinnamon, J., Taulu, T., Ricker, B. A., Brown, D. R. G., Navsaria, P. H., & Hameed, M. S. (2013) · Journal of the American College of Surgeons · doi:10.1016/j.jamcollsurg.2013.10.001 · Cited by 72
Epstein, R. H., & Dexter, F. (2012) · Anesthesiology · doi:10.1097/aln.0b013e318246ec24 · Cited by 72
Relationship Between Operating Room Teamwork, Contextual Factors, and Safety Checklist Performance
Singer, S. J., Molina, G., Li, Z., Jiang, W., Nurudeen, S. M., Kite, J. G., Edmondson, L., Foster, R. W. G., Haynes, A. B., & Berry, W. R. (2016) · Journal of the American College of Surgeons · doi:10.1016/j.jamcollsurg.2016.07.006 · Cited by 72
Self-citationPreventing Hospital-acquired Infections in Low-income and Middle-income Countries
Bardossy, A. C., Zervos, J., & Zervos, M. (2016) · Infectious Disease Clinics of North America · doi:10.1016/j.idc.2016.04.006 · Cited by 74
Collaborative, G. (2016) · BMJ Global Health · doi:10.1136/bmjgh-2016-000091 · Cited by 72
Human factors in decision making in major trauma in Camp Bastion, Afghanistan
Arul, G. S., Pugh, H., Mercer, S. J., & Midwinter, M. J. (2015) · Annals of The Royal College of Surgeons of England · doi:10.1308/003588414x14055925060875 · Cited by 71
Tillman, M. M., Wehbe–Janek, H., Hodges, B., Smythe, W. R., & Papaconstantinou, H. T. (2013) · Journal of Surgical Research · doi:10.1016/j.jss.2013.03.048 · Cited by 71
Lafaro, K. J., Stewart, C. L., Fong, A., & Fong, Y. (2020) · Surgical Clinics of North America · doi:10.1016/j.suc.2019.11.003 · Cited by 71
Andoh, A. B., Francis, A. A., Abdulkarim, A. A., Adesunkanmi, A. O., Salako, A. A., Soladoye, A., Sheshe, A. A., Sani, A., Lawal, A. O., Lawal, A. O., et al. (2022) · The Lancet · doi:10.1016/s0140-6736(22)01884-0 · Cited by 74
“Perioperative practices were largely similar to those seen in higherincome settings; 1,18,19 although this study was done in seven LMICs, there is likely to be a global effect well beyond the included countries and patients.”
Patabendige, M., & Senanayake, H. M. (2015) · BMC Pregnancy and Childbirth · doi:10.1186/s12884-015-0436-0 · Cited by 72
“With the WHO Surgical Safety Checklist [2], it has been found that its implementation was associated with concomitant reductions in the rates of deaths and complications among patients undergoing non-cardiac surgeries [3].”
MethodAdverse events in a Tunisian hospital: results of a retrospective cohort study
Letaief, M., Mhamdi, S. E., El-Asady, R. S., Siddiqi, S., & Abdullatif, A. (2010) · International Journal for Quality in Health Care · doi:10.1093/intqhc/mzq040 · Cited by 71
“The World Health Organization ‘safe surgery checklist’ led to a significant reduction in surgical mortality and morbidity rate in many countries and may be an important tool to reduce AEs in our context [16].”
BackgroundImplementation and evaluation of nationwide scale-up of the Surgical Safety Checklist
White, M. C., Randall, K., Capo‐Chichi, N., Sodogas, F., Quenum, S., Wright, K., Close, K. L., Russ, S., Sevdalis, N., & Leather, A. J. M. (2019) · British journal of surgery · doi:10.1002/bjs.11034 · Cited by 71
Important questions asked by family members of intensive care unit patients*
Peigne, V., Chaize, M., Falissard, B., Kentish‐Barnes, N., Rusínová, K., Mégarbane, B., Bèle, N., Cariou, A., Fieux, F., Garrouste-Orgeas, M., et al. (2011) · Critical Care Medicine · doi:10.1097/ccm.0b013e3182120b68 · Cited by 70
Moffatt, S. D., Hefner, J. L., Mekhjian, H. S., McAlearney, J. S., Latimer, T., Ellison, C., & McAlearney, A. S. (2015) · American Journal of Medical Quality · doi:10.1177/1062860615608938 · Cited by 69
“The 4 specific aims of this study were to (1) assess the costs of CRM implementation, (2) calculate the change in avoidable adverse events since CRM implementation, (3) estimate health system savings related to reductions in adverse events, and (4) calculate the overall ROI for the CRM program.”
WHO safe surgery checklist: Barriers to universal acceptance
Jain, D., Sharma, R., & Reddy, S. (2018) · Journal of Anaesthesiology Clinical Pharmacology · doi:10.4103/joacp.joacp_307_16 · Cited by 69
“About 79% of the staff involved thought it easy to use, 79% thought it improved care, 84% thought it improved communication, and 78% thought it reduced errors.[9] Greater benefit from the adoption of WHO checklist was seen in low- and middle-income group countries compared to the high-income group countries.”
BackgroundKatheria, A. C., Rich, W. D., & Finer, N. (2013) · Resuscitation · doi:10.1016/j.resuscitation.2013.06.012 · Cited by 70
White, R. E., Trbovich, P., Easty, A., Savage, P., Trip, K., & Hyland, S. (2010) · BMJ Quality & Safety · doi:10.1136/qshc.2009.032862 · Cited by 70
“Many studies have shown the effectiveness of checklists in improving patient safety, 16 e 18 but a recent review found very little research on the effective design of checklists.”
BackgroundReeder, S. C., Manias, E., & Riley, R. (2011) · International Journal of Nursing Studies · doi:10.1016/j.ijnurstu.2011.05.009 · Cited by 75
“Another key point this literature review underscores is the merit of preoperative checklists as documents that coordinate verbal communication (Haynes et al., 2009; Lingard et al., 2008; Weiser et al., 2010).”
BackgroundDesgranges, F., Desebbe, O., Ghazouani, A., Gilbert, K., Keller, G., Chiari, P. C., Robin, J., Bastien, O. H., Lehot, J.-J., & Cannesson, M. P. (2011) · British Journal of Anaesthesia · doi:10.1093/bja/aer165 · Cited by 69
Surgical Ward Round Quality and Impact on Variable Patient Outcomes
Pucher, P. H., Aggarwal, R. K., & Darzi, A. W. (2013) · Annals of Surgery · doi:10.1097/sla.0000000000000376 · Cited by 69
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
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