What is the evidence to support using the WHO Surgical Safety Checklist?
There is substantial evidence supporting the use of the WHO checklist. The following are some of the important articles, for a full bibliography please visit our website here.
1. Haynes AB et al. A surgical safety checklist to reduce morbidity and mortality in a global population. N Engl J Med. 2009 Jan 29;360(5):491-9. Epub 2009 Jan 14.
This WHO study that included eight evaluation sites around the globe and nearly 8,000 patients. Each site had a principle investigator to help put the checklist in place in some of their operating rooms to see what it did in terms both of changing the way people did their work and changing the outcomes of the patients. The combined results from all of the sites made a difference in mortality, the incidence of any complications, the incidence of surgical site infection, and the incidence of any unplanned reoperation. Most notable, inpatient deaths following surgery fell by more than 40 percent with the implementation of the checklist.
2. Weiser TG, Haynes AB, Dziekan G, Berry WR, Lipsitz SR, Gawande AA; Safe Surgery Saves Lives Investigators and Study Group. Effect of a 19-item surgical safety checklist during urgent operations in a global patient population. Ann Surg. 2010 May;251(5):976-80.
In this article, investigators looked at the effect of a 19 item surgical checklist used during urgent operations. This study reinforced that the checklist works and can be useful in operations that need to be done urgently.
3. Tsai Thomas, Boussard Tinna, Welton, Mark, Morton, John. Does a surgical safety checklist improve patient safety culture and outcomes? [Abstract]. In: American College of Surgeons Annual Clinical Congress. 2010 October 3-7; Washington D.C. Journal of American College of Surgeons.
In an October presentation from the American College of Surgeons Annual Clinical Congress, the checklist was implemented at Stanford and found mortality declined from .88 to .8. The total number of reported cases rose; however, those that were attributed to errors or complications decreased from 35.3% to 24.3%. Additionally, after the checklist was put into place, the mean OR start to incision time was shorter and there was an improvement in the belief that all personnel take responsibility for patient safety.
4. Neily J, Mills PD, Young-Xu Y, Carney BT, West P, Berger DH, Mazzia LM, Paull DE, Bagian JP. Association between implementation of a medical team training program and surgical mortality. JAMA. 2010 Oct 20; 304(15):1693-700.
The Veterans Health Affairs looked at a surgical team training program that was implemented and incorporated a modified version of the surgical checklist in the operating rooms of 74 facilities. In this study, they found a reduction in mortality rate of 18%. One year later in a follow-up study, facilities that participated in the program experienced a risk-adjusted morbidity reduction of 17% versus 6%.
5. de Vries EN et. al. Effect of a Comprehensive Surgical Safety System on Patient Outcomes. N Engl J Med. 2011 Nov 11; 363: 1928-1937.
This article looked at the SURPASS checklist which was used in hospitals in the Netherlands. This was a 100 item checklist that was implemented in six high performing hospitals and follows the patient from the admission through the discharge. It was found that compared to the controls, the test hospitals had a greater than one third reduction in complications and achieved an almost 50% reduction rate in deaths (from 1.5% to 0.8%).
6. Takala RS, Pauniaho SL, Kotkansalo A, et al.: A pilot study of the implementation of WHO surgical checklist in Finland: improvements in activities and communication. Acta Anaesthesiol Scand 2011; 55: 1206–14
A pilot study of the implementation of the WHO checklist looked deeply into what happens to the way critical events in the OR are discussed before and after the checklist implementation. This article showed that critical events were talked about 22% of the time before implementation of the checklist by anesthesiologists and this increased to 43% after checklist implantation. Similarly, looking at surgeons, their discussion of critical events increased from 35% to 46%.
7. van Klei WA, Hoff RG, van Aarnhem EE, Simmermacher RK, Regli LP, Kappen TH, van Wolfswinkel L, Kalkman CJ, Buhre WF, Peelen LM. Effects of the Introduction of the WHO "Surgical Safety Checklist" on In-Hospital Mortality: A Cohort Study. Ann Surg. 2012 Jan;255(1):44-9.
Another study from the Netherlands looked at over 25,000 adult patients undergoing non-day surgery. This study found crude morality decreased from 3.13% to 2.85%. When checklist compliance was measured, it was found that mortality was significantly lower in patients with completed checklists.
8. Bliss LA, Ross-Richardson CB, Sanzari LJ, Shapiro DS, Lukianoff AE, Bernstein BA, Ellner SJ. Thirty-Day Outcomes Support Implementation of a Surgical Safety Checklist. J Am Coll Surg. 2012 Aug 27.
Use of a comprehensive surgical checklist and a structured team training program can significantly decrease 30-day morbidity rates. This study implemented three 60-minute team training sessions and taught teams about the checklist use. They found that the adoption of the checklist is feasible in conjunction with a team training program and can significantly improve patient outcomes.
For more information on checklist evidence, please see our webinar here.