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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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“…in structured clinical examinations may mimic a novice’s approach to problem solving, which tends to be detailed and stepwise (Norman et al., 1985), but even expert-written, case-specific checklists for OSCE examinations do not coincide with evidence-based pedagogy (Hettinga et al., 2010).”
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Training in robotic surgery, replicating the airline industry. How far have we come?
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“Quality-improvement programmes have been shown to enhance organisational performance.(11) 12 However, their limitations have been recognised.”
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“The use of a universal protocol/checklist and time-out based on the World Health Organisation (WHO) Surgical Safety model (19) should be encouraged for all pleural procedures and can reduce the risk of avoidable complications (20,21), even in pressurised emergency situations (22).”
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“Studies using this checklist have shown a significant decrease in surgery-related complications and in-hospital deaths.(7) 8 Other medical and procedural checklists have similarly improved morbidity, mortality and other patient quality metrics.”
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“All sites had a reduction in the rate of major postoperative complications, with a significant reduction at three sites, one in a high-income location and two in lower-income locations [7].”
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A New Frontier in Patient Safety
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“Monitors 100 136 9 (7) 14 (14) 54 (40) 6 (6) 14 (10) Infusion devices 74 694 20 (3) 27 (36) 274 (39) 7 (9) 17 (2) Ventilation 193 347 17 (5) 31 (16) 105 (30) 11 (6) 17 (5) Dialysis — 183 20 (11) — 59 (32) — 8 (4) Drainage — 88 1 (1) — 18 (20) — 0 (—) Transfusion — 130 3 (2) — 32 (25) — 3 (2) Total (%) 471 1935‡ 105 (5…”
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“Checklists break down complex processes into simple steps, and their use has improved performance and reduced error rates in the airline industry and medicine (8, 19, 20).”
BackgroundIntroduction to the postanaesthetic care unit
Simpson, J. C., & Moonesinghe, R. (2013) · Perioperative Medicine · doi:10.1186/2047-0525-2-5 · Cited by 51
Slankamenac, K., Graf, R., Puhan, M. A., & Clavien, P. (2011) · Patient Safety in Surgery · doi:10.1186/1754-9493-5-30 · Cited by 47
“This Clavien-Dindo classification has currently been used in more than 350 studies from various surgical fields [22-28] and was also proposed as a possible gold standard to assess post-operative complications [4].”
MethodMainthia, R., Lockney, T., Зотов, А. С., France, D. J., Bennett, M. L., Jacques, P. J. S., Furman, W. R., Randa, S., Feistritzer, N. R., Eavey, R. D., et al. (2012) · Surgery · doi:10.1016/j.surg.2011.12.005 · Cited by 45
Effect of surgical safety checklists on pediatric surgical complications in Ontario
O’Leary, J. D., Wijeysundera, D. N., & Crawford, M. W. (2016) · Canadian Medical Association Journal · doi:10.1503/cmaj.151333 · Cited by 45
Republished: 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) · Postgraduate Medical Journal · doi:10.1136/postgradmedj-2014-003620rep · Cited by 49
Neis, K. J., Zubke, W., Römer, T., Schwerdtfeger, K., Schollmeyer, T., Rimbach, S., Holthaus, B., Solomayer, E., Bojahr, B., Neis, F., et al. (2016) · Geburtshilfe und Frauenheilkunde · doi:10.1055/s-0042-104288 · Cited by 45
Wandersman, A., Alia, K. A., Cook, B. S., Hsu, L. L.-Y., & Ramaswamy, R. (2016) · American Journal of Evaluation · doi:10.1177/1098214016660613 · Cited by 46
“Other checklist studies (Averling, McCuloch, & Dixon-Woods, 2013; Haynes et al., 2009) mention the Hawthorne effect, differences in resources, hierarchical relationships, physician indifference, and skepticism as possible facilitators and barriers to the achievement of outcomes.”
BackgroundKowark, A., Beckers, S. K., Czaplik, M., Bergrath, S., Coburn, M., Brokmann, J. C., Hilgers, R.-D., & Rossaint, R. (2017) · Trials · doi:10.1186/s13063-017-1781-2 · Cited by 45
Preventing the Forgotten Ureteral Stent by Using a Mobile Point-of-Care Application
Ziemba, J. B., Ludwig, W. W., Ruiz, L., Carvalhal, E., & Matlaga, B. R. (2017) · Journal of Endourology · doi:10.1089/end.2017.0118 · Cited by 45
Sileshi, B., Newton, M. W., Kiptanui, J., Shotwell, M. S., Wanderer, J. P., Mungai, M., Scherdin, J., Harris, P. A., Vermund, S. H., Sandberg, W. S., et al. (2017) · Anesthesiology · doi:10.1097/aln.0000000000001713 · Cited by 45
White, M. C., Randall, K., Ravelojaona, V., Andriamanjato, H. H., Andean, V., Callahan, J., Shrime, M. G., Russ, S., Leather, A. J. M., & Sevdalis, N. (2018) · BMJ Global Health · doi:10.1136/bmjgh-2018-001104 · Cited by 45
“This checklist reduces mortality and morbidity after surgery by up to 50% with the biggest gains in low-income and middle-income countries (LMICs).(5) Since the launch of the checklist, repeated studies have shown similar benefit across a wide variety of settings.”
BackgroundLiu, T., Xu, C., Wang, M., Niu, Z., & Qi, D. Y. (2019) · BMC Anesthesiology · doi:10.1186/s12871-019-0744-4 · Cited by 49
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An exploration of management practices in hospitals
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Mathew, R. G., Ferguson, V., & Hingorani, M. (2012) · Ophthalmology · doi:10.1016/j.ophtha.2012.01.009 · Cited by 44
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The path to safe and reliable healthcare
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“Allan Frankel’s distillation of James Reason’s Unsafe Act Algorithm and David Marx’s Just Culture model results in being able to ask a very short list of questions: was the harm intentional? [6,7] See Fig.”
BackgroundProgress and challenges in improving surgical outcomes1
Birkmeyer, J. D. (2012) · British journal of surgery · doi:10.1002/bjs.8933 · Cited by 43
Wrong intraocular lens implant; learning from reported patient safety incidents
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Adherence to the use of the surgical checklist for patient safety
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Krishnaswami, S., Stephens, C. Q., Yang, G. P., Nwomeh, B. C., Swaroop, M., Nadler, E. P., Holterman, A., Simeone, D. M., Kingham, T. P., Merchant, N. B., et al. (2017) · Surgery · doi:10.1016/j.surg.2017.10.019 · Cited by 44
Forecasting methods and principles: Evidence-based checklists
Armstrong, J. S., & Green, K. C. (2018) · Journal of Global Scholars of Marketing Science · doi:10.1080/21639159.2018.1441735 · Cited by 49
“Use of the checklist reduced deaths from 1.5% to 0.8% in the month after the medical procedures (Haynes et al. 2009).”
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Anesthesia Patient Safety: Next Steps to Improve Worldwide Perioperative Safety by 2030
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Economics of ICU Organization and Management
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“Some of these options have been examined as individual components (such as checklists [65]) and others as “bundles” of care to be delivered together [64,66].”
BackgroundWhat Do We Know About the Safe Surgery Checklist Now?
Haynes, A. B., Berry, W. R., & Gawande, A. A. (2015) · Annals of Surgery · doi:10.1097/sla.0000000000001144 · Cited by 44
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The limits of checklists: handoff and narrative thinking
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Simulation-based acquisition of non-technical skills to improve patient safety
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Enhancing T Cell Chemotaxis and Infiltration in Glioblastoma
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“CCL4 binds CCL22 (and others), which has been shown to be overexpressed in freshly resected human glioma cells, and blockade of CCR4 in vitro can significantly reduce regulatory T cell migration [135].”
BackgroundChen, Y., Harris, S. K., Rogers, Y., Ahmad, T., & Asselbergs, F. W. (2022) · European Heart Journal · doi:10.1093/eurheartj/ehac030 · Cited by 44
Otsubo, T., Kobayashi, S., Sano, K., Misawa, T., Katagiri, S., Nakayama, H., Suzuki, S., Watanabe, M., Ariizumi, S., Unno, M., et al. (2022) · Journal of Hepato-Biliary-Pancreatic Sciences · doi:10.1002/jhbp.1186 · Cited by 43
“5,6 The system is designed to (1) designate specific procedures as highly advanced HBPSs, (2) certify qualified institutions as boardcertified training institutions, (3) certify instructors, and (4) certify expert surgeons.”
BackgroundReview article: Practical current issues in perioperative patient safety
Eichhorn, J. H. (2012) · Canadian Journal of Anesthesia/Journal canadien d anesthésie · doi:10.1007/s12630-012-9852-z · Cited by 43
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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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