BMJ Qual Saf 20:102-107 doi:10.1136/bmjqs.2009.040022

Changes in safety attitude and relationship to decreased postoperative morbidity and mortality following implementation of a checklist-based surgical safety intervention

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  1. for the Safe Surgery Saves Lives Study Group
  1. 1Department of Health Policy and Management, Harvard School of Public Health, Boston, Massachusetts, USA
  2. 2Center for Surgery and Public Health, Brigham and Women’s Hospital, Boston, Massachusetts, USA
  3. 3Department of Surgery, Prince Hamzah Hospital, Ministry of Health, Amman, Jordan
  4. 4Department of Surgery, University of Washington, Seattle, Washington, USA
  5. 5Patient Safety Programme, World Health Organization, Geneva, Switzerland
  6. 6Department of Surgery, College of Medicine, University of the Philippines, Manila, Philippines
  7. 7Department of Surgery, St Francis Designated District Hospital, Ifakara, Tanzania
  8. 8National Institute of Health, University of the Philippines, Manila, Philippines
  9. 9Department of Anaesthesiology, University of Auckland, Auckland, New Zealand
  10. 10Department of Surgery, University Health Network, University of Toronto, Ontario, Canada
  11. 11Department of Surgery, Imperial College Healthcare NHS Trust, London, UK
  1. Correspondence to Dr Atul A Gawande, Department of Health Policy and Management, Harvard School of Public Health, 677 Huntington Avenue, Kresge 440, Boston, MA 02115, USA; safesurgery{at}
  1. Contributors ABH and AAG jointly led the study and are guarantors. All authors participated in the study design, interpretation of the results, drafting and critical revision of the manuscript. ABH and SRL carried out the statistical analyses.

  • Accepted 20 September 2010


Objectives To assess the relationship between changes in clinician attitude and changes in postoperative outcomes following a checklist-based surgical safety intervention.

Design Pre- and post intervention survey.

Setting Eight hospitals participating in a trial of a WHO surgical safety checklist.

Participants Clinicians actively working in the designated study operating rooms at the eight hospitals.

Survey instrument Modified operating-room version Safety Attitudes Questionnaire (SAQ).

Main outcome measures Change in mean safety attitude score and correlation between change in safety attitude score and change in postoperative outcomes, plus clinician opinion of checklist efficacy and usability.

Results Clinicians in the preintervention phase (n=281) had a mean SAQ score of 3.91 (on a scale of 1 to 5, with 5 representing better safety attitude), while the postintervention group (n=257) had a mean of 4.01 (p=0.0127). The degree of improvement in mean SAQ score at each site correlated with a reduction in postoperative complication rate (r=0.7143, p=0.0381). The checklist was considered easy to use by 80.2% of respondents, while 19.8% felt that it took a long time to complete, and 78.6% felt that the programme prevented errors. Overall, 93.4% would want the checklist used if they were undergoing operation.

Conclusions Improvements in postoperative outcomes were associated with improved perception of teamwork and safety climate among respondents, suggesting that changes in these may be partially responsible for the effect of the checklist. Clinicians held the checklist in high regard and the overwhelming majority would want it used if they were undergoing surgery themselves.


  • Safe Surgery Saves Lives Study Group: Amman: AS Breizat, AF Awamleh, OG Sadieh; Auckland: AF Merry, SJ Mitchell, V Cochrane, A-M Wilkinson, J Windsor, N Robertson, N Smith, W Guthrie, V Beavis; Ifakara: P Kibatala, B Jullu, R Mayoka, M Kasuga, W Sawaki, N Pak; London: A Darzi, K Moorthy, A Vats, R Davies, K Nagpal, M Sacks; Manila: G Herbosa, T Herbosa, MCM Lapitan, C Meghrajani; New Delhi: S Joseph, A Kumar, H Singh Chauhan; Seattle: EP Dellinger, K Gerber; Toronto RK Reznick, B Taylor, A Slater; Boston: WR Berry, AA Gawande, AB Haynes, SR Lipsitz, TG Weiser; Geneva: L Donaldson, G Dziekan, P Philip; Baltimore: M Makary; Ankara: I Sayek, Sydney B Barraclough.

  • Funding This study was funded by the WHO. The WHO had no role in study design, analysis or interpretation of data, or on the decision to publish.

  • Competing interests None.

  • Ethics approval The study was approved by the Human Subjects Committee of the Harvard School of Public Health, as well as by the ethics approval body at each of the participating hospitals.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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