Cited by 5,688Patient Safety and Medication ErrorsCardiac, Anesthesia and Surgical OutcomesSurgical site infection prevention

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A Surgical Safety Checklist to Reduce Morbidity and Mortality in a Global Population

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Haynes, Alex B., Weiser, Thomas G., Berry, William R., Lipsitz, Stuart R., Breizat, Abdel-Hadi S., Dellinger, E. Patchen, Herbosa, Teodoro, Joseph, Sudhir, Kibatala, Pascience L., Lapitan, Marie Carmela M., Merry, Alan F., Moorthy, Krishna, Reznick, Richard K., Taylor, Bryce, Gawande, Atul A.·2009·New England Journal of Medicine

DOI 10.1056/nejmsa0810119

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Abstract

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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Savage, C., Gaffney, F. A., Hussain‐Alkhateeb, L., Olsson-Ackheim, P., Henricson, G., Antoniadou, I., Hedsköld, M., & Härenstam, K. P. (2017) · International Journal for Quality in Health Care · doi:10.1093/intqhc/mzx113 · Cited by 40
Research versus practice in quality improvement? Understanding how we can bridge the gap
Hirschhorn, L. R., Ramaswamy, R., Devnani, M., Wandersman, A., Simpson, L., & García‐Elorrio, E. (2018) · International Journal for Quality in Health Care · doi:10.1093/intqhc/mzy018 · Cited by 45
“A well-known and commonly cited example is the Surgical Safety Checklist, which was found to improve adherence to evidence-based practices and save lives across a range of settings [14].”
Background
A mixed methods study of challenges in the implementation and use of the surgical safety checklist
Mahmood, T., Mylopoulos, M., Bägli, D., Damignani, R., & Haji, F. A. (2018) · Surgery · doi:10.1016/j.surg.2018.09.012 · Cited by 40
A Team‐Based Approach to Introduce and Sustain the Use of the WHO Surgical Safety Checklist in Tanzania
Hellar, A. M., Tibyehabwa, L., Ernest, E., Varallo, J. E., Bertram, M. M., Fitzgerald, L., Giiti, G. C., Kihundrwa, A., Kapologwe, N., Drake, M., et al. (2019) · World Journal of Surgery · doi:10.1007/s00268-019-05292-5 · Cited by 40
Plastic Surgery and the Malpractice Industry
Boyd, J. B., Moon, H. K., Martin, S., & Mastrogiovanni, D. B. (2020) · Plastic & Reconstructive Surgery · doi:10.1097/prs.0000000000007497 · Cited by 39
Sex omission and male bias are still widespread in cell experiments
Kim, J. Y., Min, K., Paik, H. Y., & Lee, S. K. (2021) · American Journal of Physiology-Cell Physiology · doi:10.1152/ajpcell.00358.2020 · Cited by 44
Surgical time out checklist with debriefing and multidisciplinary feedback improves venous thromboembolism prophylaxis in thoracic surgery: a prospective audit
Berrisford, R. G., Wilson, I. H., Davidge, M., & Sanders, D. (2011) · European Journal of Cardio-Thoracic Surgery · doi:10.1093/ejcts/ezr179 · Cited by 40
“In 2008, the second WHO Global Patient Safety Challenge– Safer Surgery issued a three-step Safer Surgery Checklist which reported reductions in mortality and morbidity from surgery performed in eight different surgical centres [7].”
Background
Safety skills training for surgeons: A half-day intervention improves knowledge, attitudes and awareness of patient safety
Arora, S., Sevdalis, N., Ahmed, M., Wong, H. W. L., Moorthy, K., & Vincent, C. A. (2012) · Surgery · doi:10.1016/j.surg.2012.02.006 · Cited by 40
Self-citation
The association of intensivists with failure-to-rescue rates in outlier hospitals: Results of a national survey of intensive care unit organizational characteristics
Wakeam, E., Asafu-Adjei, D. A., Ashley, S. W., Cooper, Z. R., & Weissman, J. S. (2014) · Journal of Critical Care · doi:10.1016/j.jcrc.2014.06.010 · Cited by 41
“We included factors thought to influence ICU outcomes such as ICU model of care (open, closed, or mixed model) [16,17], teaching programs, structure of rounds, and overnight staffing [11,12] as well as others [11,12,18-33].”
Method
The Importance of Transurethral Resection in Managing Patients With Urothelial Cancer in the Bladder: Proposal for a Transurethral Resection of Bladder Tumor Checklist
Pan, D., & Soloway, M. S. (2012) · European Urology · doi:10.1016/j.eururo.2012.03.018 · Cited by 40
“In the following year, Haynes and colleagues published the most convincing data supporting the idea that the WHO checklist improves the safety of surgical patients [11].”
Background
The medical pause: Importance, processes and training
Lee, J. Y., Szulewski, A., Young, J. Q., Donkers, J. H. H. L. M., Jarodzka, H., & van Merriënboer, J. J. G. (2021) · Medical Education · doi:10.1111/medu.14529 · Cited by 44
Surgical safety checklist compliance: The clinical audit
Gul, F., Nazir, M., Abbas, K., Khan, A. A., Malick, D. S., Khan, H., Kazmi, S. N. H., & Naseem, A. O. (2022) · Annals of Medicine and Surgery · doi:10.1016/j.amsu.2022.104397 · Cited by 39
“Implementation of the surgical safety checklist has shown to not only decrease operative morbidity and mortality [3,5] but also foster a patient safety culture and enhances communication [6].”
Background
Postoperative abdominal wound infection – epidemiology, risk factors, identification, and management
Eckhäuser, F. E., Azoury, S. C., Farrow, N., Hu, Q., Soares, K. C., Hicks, C. W., Azar, F. K., Rodriguez-Unda, N. A., Poruk, K. E., Cornell, P., et al. (2015) · Chronic Wound Care Management and Research · doi:10.2147/cwcmr.s62514 · Cited by 39
“Simply introducing a surgical safety checklist has even been shown to reduce morbidity and mortality in noncardiac surgery patients.(91) Advances in surgical approach, including laparoscopy, intraoperative wound irrigation, the use of wound protectors during an operation, and negative pressure wound therapy (NPWT) sys…”
Identifying and Addressing Preventable Process Errors in Trauma Care
Pucher, P. H., Aggarwal, R., Twaij, A., Batrick, N., Jenkins, M. P., & Darzi, A. W. (2013) · World Journal of Surgery · doi:10.1007/s00268-013-1917-9 · Cited by 41
“Such an approach has been demonstrated to be an effective method of error reduction and outcome improvement in other clinical arenas, such as the World Health Organization Surgical Safety Checklist for surgical procedures [25], World J Surg (2013) 37:752–758 755”
Method
Preoperative Surgical Briefings Do Not Delay Operating Room Start Times and Are Popular With Surgical Team Members
Ali, M. F., Osborne, A., Bethune, R. M., & Pullyblank, A. M. (2011) · Journal of Patient Safety · doi:10.1097/pts.0b013e31822a9fbc · Cited by 39
Care Redesign — A Path Forward for Providers
Lee, T. H.-Y. (2012) · New England Journal of Medicine · doi:10.1056/nejmhpr1204386 · Cited by 41
Teleconsultation in pre-hospital emergency medical services: Real-time telemedical support in a prospective controlled simulation study
Skorning, M. H., Bergrath, S., Rörtgen, D., Beckers, S. K., Brokmann, J. C., Gillmann, B., Herding, J., Protogerakis, M., Fitzner, C., & Rossaint, R. (2011) · Resuscitation · doi:10.1016/j.resuscitation.2011.10.029 · Cited by 38
Root Cause Analysis of Serious Adverse Events Among Older Patients in the Veterans Health Administration
Lee, A. M., Mills, P. D., Neily, J. B., & Hemphill, R. R. (2014) · The Joint Commission Journal on Quality and Patient Safety · doi:10.1016/s1553-7250(14)40034-5 · Cited by 39
Guideline for obtaining valid consent for gastrointestinal endoscopy procedures
Everett, S. M., Griffiths, H. R., Nandasoma, U., Ayres, K., Bell, G., Cohen, M., Thomas‐Gibson, S., Thomson, M. A., & Naylor, K. M. T. (2016) · Gut · doi:10.1136/gutjnl-2016-311904 · Cited by 39
Interprofessional and interdisciplinary simulation-based training leads to safe sedation procedures in the emergency department
Sauter, T. C., Hautz, W. E., Hostettler, S., Maeder, M. B., Martinolli, L., Lehmann, B., Exadaktylos, A. K., & Haider, D. G. (2016) · Scandinavian Journal of Trauma Resuscitation and Emergency Medicine · doi:10.1186/s13049-016-0291-7 · Cited by 39
Attitudes and beliefs about the surgical safety checklist: Just another tick box?
Dharampal, N., Cameron, C., Dixon, E., Ghali, W. A., & Quan, M. L. (2016) · Canadian Journal of Surgery · doi:10.1503/cjs.002016 · Cited by 40
Characteristics of Medical Liability Claims Against Dermatologists From 1991 Through 2015
Kornmehl, H. A., Singh, S., Adler, B. L., Wolf, A. E., Bochner, D. A., & Armstrong, A. W. (2017) · JAMA Dermatology · doi:10.1001/jamadermatol.2017.3713 · Cited by 39
Anaesthesia-specific checklists: A systematic review of impact
Saxena, S., Krombach, J. W., Nahrwold, D. A., & Pirracchio, R. (2019) · Anaesthesia Critical Care & Pain Medicine · doi:10.1016/j.accpm.2019.07.011 · Cited by 39
Review of alternatives to root cause analysis: developing a robust system for incident report analysis
Hagley, G., Mills, P. D., Watts, B. V., & Wu, A. W. (2019) · BMJ Open Quality · doi:10.1136/bmjoq-2019-000646 · Cited by 39
Downstream hospital system effects of a comprehensive trauma recovery services program
DeMario, B. S., Kalina, M. J., Truong, E. I., Hendrickson, S. B., Tseng, E. S., Claridge, J. A., Vallier, H. A., & Ho, V. P. (2020) · The Journal of Trauma: Injury, Infection, and Critical Care · doi:10.1097/ta.0000000000002872 · Cited by 39
Reducing Error and Improving Efficiency during Vascular Interventional Radiology: Implementation of a Preprocedural Team Rehearsal
Morbi, A. H. M., Hamady, M., Riga, C. V., Kashef, E., Pearch, B. J., Vincent, C. A., Moorthy, K., Vats, A., Cheshire, N. J. W., & Bicknell, C. D. (2012) · Radiology · doi:10.1148/radiol.12110530 · Cited by 39
Self-citation
National and Institutional Trends in Adverse Events Over Time: A Systematic Review and Meta-analysis of Longitudinal Retrospective Patient Record Review Studies
Connolly, W., Li, B., Conroy, R. M., Hickey, A., Williams, D. J., & Rafter, N. (2020) · Journal of Patient Safety · doi:10.1097/pts.0000000000000804 · Cited by 39
Multivariate logistic regression analysis of postoperative complications and risk model establishment of gastrectomy for gastric cancer: A single-center cohort report
Zhou, J., Zhou, Y., Cao, S., Li, S., Wang, H., Niu, Z., Chen, D., Wang, D., Lv, L., Zhang, J., et al. (2015) · Scandinavian Journal of Gastroenterology · doi:10.3109/00365521.2015.1063153 · Cited by 36
“For evaluating and improving the safety of surgery, as one of the standard composite endpoints, this systemhas been validated in a large cohort of patients andhas universal applicability [8,9].”
Background
Attitudes to teamwork and safety among Italian surgeons and operating room nurses
Prati, G., & Pietrantoni, L. (2014) · Work · doi:10.3233/wor-131702 · Cited by 38
“These findings suggest that interventions to improve the dialogue between team members to create a shared mental model would be useful [26,35–38].”
Background
La interconsulta médica: problemas y soluciones
Ruiz, E. M., & Álvarez, J. L. (2009) · Medicina Clínica · doi:10.1016/j.medcli.2009.06.039 · Cited by 38
Missed opportunities in TB diagnosis: a TB Process-Based Performance Review tool to evaluate and improve clinical care
Field, N. M., Murray, J., Wong, M., Dowdeswell, R., Dudumayo, N., Rametsi, L., Martinson, N. A., Lipman, M. C. I., Glynn, J. R., & Sonnenberg, P. (2011) · BMC Public Health · doi:10.1186/1471-2458-11-127 · Cited by 38
“Similarly, implementation of a 19point checklist of simple clinical actions was associated with significant improvements in surgical outcome [32].”
Background
The surgical safety checklist survey: a national perspective on patient safety
Nugent, E., Hseino, H., Ryan, K., Traynor, O. J., Neary, P. C., & Keane, F. B. V. (2012) · Irish Journal of Medical Science (1971 -) · doi:10.1007/s11845-012-0851-4 · Cited by 38
Complications in Surgery
Chung, K. C., & Kotsis, S. V. (2012) · Plastic & Reconstructive Surgery · doi:10.1097/prs.0b013e31824ecda0 · Cited by 38
Making existing technology safer in healthcare
Newton, R. C., Mytton, O. T., Aggarwal, R., Runciman, W. B., Free, M. J., Fahlgren, B., Akiyama, M., Farlow, B., Yaron, S., Locke, G., et al. (2010) · BMJ Quality & Safety · doi:10.1136/qshc.2009.038539 · Cited by 39
“The checklist has been shown to reduce both patient morbidity and mortality in both developed and developing nations.(58) There is now a drive for widespread use of the checklist.”
Background
The Effect of Facility Complexity on Perceptions of Safety Climate in the Operating Room: Size Matters
Carney, B. T., West, P., Neily, J. B., Mills, P. D., & Bagian, J. P. (2010) · American Journal of Medical Quality · doi:10.1177/1062860610368427 · Cited by 38
ACROSCORE : a new and simple tool for the diagnosis of acromegaly, a rare and underdiagnosed disease
Prencipe, N., Floriani, I., Guaraldi, F., Giacomo, S. D., Cannavò, S., Arnaldi, G., Berton, A. M., Torri, V., Spinello, M., Arvat, E., et al. (2015) · Clinical Endocrinology · doi:10.1111/cen.12959 · Cited by 38
A ‘paperless’ wall-mounted surgical safety checklist with migrated leadership can improve compliance and team engagement
Ong, A. P. C., Devcich, D. A., Hannam, J. A., Lee, T., Merry, A., & Mitchell, S. J. (2015) · BMJ Quality & Safety · doi:10.1136/bmjqs-2015-004545 · Cited by 38
Self-citation
Comparison of National Operative Mortality in Gastroenterological Surgery Using Web-based Prospective Data Entry Systems
Anazawa, T., Paruch, J. L., Miyata, H., Gotoh, M., Ko, C. Y., Cohen, M. E., Hirahara, N., Zhou, L., Konno, H., Wakabayashi, G., et al. (2015) · Medicine · doi:10.1097/md.0000000000002194 · Cited by 38
“morbidity and decrease mortality rates.(10,29) Relatively longer hospital stays after surgery due to the insurance system in Japan(30) may protect patients with high morbidity after surgery,”
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Excess Surgical Mortality: Strategies for Improving Quality of Care
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‘Safety by DEFAULT’: introduction and impact of a paediatric ward round checklist
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Background

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: Haynes, Alex B.
Weiser, Thomas G.
Berry, William R.
Lipsitz, Stuart R.
Dellinger, E. Patchen
Lapitan, Marie Carmela M.
Merry, Alan F.
Moorthy, Krishna
Reznick, Richard K.
Gawande, Atul A.
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
DOI: 10.1056/nejmsa0810119
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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A Surgical Safety Checklist to Reduce Morbidity and Mortality in a Global Population

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