American College Of Surgeons - Inspiring Quality: Highest Standards, Better Outcomes

Surgeons recount the challenges of implementing the WHO Surgical Safety Checklist

OCTOBER 23, 2018
Clinical Congress Daily Highlights, Tuesday Second Edition

It has been 10 years since the launch of the World Health Organization (WHO) Surgical Safety Checklist.

The checklist is a simple tool designed to improve the safety of surgical procedures by bringing together the whole operating team to perform key safety checks during vital phases of perioperative care: prior to the induction of anesthesia, prior to skin incision and before the team leaves the operating room.

Although the checklist is a simple tool, effectively implementing it in hospitals across the world has been challenging for a number of reasons, which a panel considered on Tuesday.

Checklist adoption and subsequent mortality reduction depends on the implementation approach and setting, said Atul A. Gawande, MD, MPH, FACS, Brigham and Women’s Hospital, Boston. The more implementation readiness and intensity in adopting the checklist, the higher the reduction in mortality, he said.

Dr. Gawande pointed to multiple examples to support his point:

  • In Ontario, there was a mandate but no mortality reduction;
  • In South Carolina, there was a voluntary effort but with light-touch support, and there was a 22 percent reduction;
  • With a mandate and team training, the Veterans Health Administration saw an 18 percent reduction;
  • A mandate and regular feedback led to reductions in Scotland of 26 percent, France of 35 percent, and Norway 43 percent;
  • When done by Ariadne Labs, a partnership between a major Boston hospital and Harvard University led by Dr. Gawande, providing weekly support at pre-selected sites, the reduction was 47 percent.

South Carolina saw a 22 percent reduction in postsurgical deaths in hospitals that completed a voluntary, statewide program to implement the checklist. The study, which appeared in the August 2017 Annals of Surgery, was the first to demonstrate large-scale population-wide impact of the checklist, Dr. Gawande said.

Culture is an important element in successful implementation of the checklist, which requires a stepwise presentation of the checklist tool, customization, pilot testing, staff training, monitoring, and expansion. Cultural resistance can prolong that process from weeks to months or years. The challenges to the checklist are even greater outside the U.S. and Europe, he said.

In Colombia, challenges to effectively using the checklist include major trauma, busy days, frequent changes of staff, and getting people to speak up,  said Adriana Margarita Serna Lozano, MD, Clínica de Marly, Bogotá, Colombia.

She said surgeons can be especially resistant to embracing the checklist. Dr. Lozano surveyed 23 surgeons and found that only 43 percent always completed the checklist, while 69 percent thought the checklist always improves communication.

The checklist lessons Dr. Serna Loranzo learned include:

  • Do not leave outcomes to chance;
  • Be consistent in following the process;
  • Teamwork depends on good communication and everyone knowing their tasks;
  • The safety of the environment is a priority;
  • Consistency is important;
  • Leadership and advocacy leads to checklist compliance;
  • Improvements are needed to surgical outcomes reporting systems and databases.

In West Africa, although most hospitals and surgeons know about the checklist, implementation has been low, said King-David Terna Yawe, MD, University of Abuja, Nigeria.

“Acceptance is low among senior surgeons,” Dr. Yawe said. “Implementation is better among higher-income countries.”

The challenges, especially among low-income countries, include poor understanding of the checklist, lack of manpower to implement it, lack of cooperation in completing the checklist, lack of responsibility, lack of support from leadership, and national policy. In addition, the checklist process is hindered among low-income countries by equipment issues and lack of lack of basics such as blood and oxygen.

Necessary to improve implementation of the checklist, Dr. Yawe said, is strong local leadership to drive process, training workshops, providing an electronic version of the checklist to eliminate paperwork, and monthly meetings for feedback.

In the question period after the presentations, the panelists were asked about the challenges of counting items, such as gauze pads and sponges, to ensure that none are left in the patient – mistakes are often made when the number of items exceeds 10.

Distractions, complexity, and speed all hinder accurate counting, Dr. Gawande said. Plus it can be hard to accurately complete a menial and boring task.

"If you've ever counted a deck of cards and tried to confirm whether you have 52 cards, you will often end up with 51 or 53,” Dr. Gawande said.

Despite the penchant for error, about one sponge in 3,000 sponges is left in a patient, Dr. Gawande said. That sounds impressively low, until you realize that those people are at risk for developing sepsis and needing additional surgery to remove the sponge. He said the research shows that 9 percent more sponges are left in emergency cases, and that for every one point higher Body Mass Index, there is a 10 percent greater chance of a sponge being left behind.

Barcoding and other automated processes may help track the sponges, but only 18 percent of U.S. hospitals have implemented barcoding, Dr. Gawande said.

One surgeon asked why successfully implementing a change like the checklist often requires a tragedy in which a preventable error harmed or killed a patient.

Dr. Gawande said that training should start with the participants writing about an incident in the operating room in which something went seriously wrong.

“Everyone has a story – a child died, an airway was lost,” Dr. Gawande said.

Remembering such experiences powerfully reinforces the potential value of the checklist, he said.

Additional Information:

The Panel Session, Checking in on the Checklist - Ten Years of the WHO Surgical Safety Checklist, was held October 23, at the 2018 Clinical Congress of the American College of Surgeons in Boston. Program, webcast and audio information is available online at

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