BMJ Qual Saf 21:191-197 doi:10.1136/bmjqs-2011-000094
  • Original research

Barriers to staff adoption of a surgical safety checklist

Open Access
  1. Etienne Minvielle1
  1. 1Quality Department, Institut Gustave Roussy, Villejuif, France
  2. 2Department of Anesthesia, Institut Paoli Calmettes, Marseille, France
  3. 3Quality Department, Féderation Nationale des Centres de Lutte Contre le Cancer, Paris, France
  4. 4Department of Anesthesia, Institut Gustave Roussy, Villejuif, France
  1. Correspondence to Aude Fourcade, Quality Department, Institut Gustave Roussy, 114, rue Edouard Vaillant, Villejuif cedex 94805, France; aude.fourcade{at}
  1. Contributors Aude Fourcade and Etienne Minvielle are responsible for the conception and design, analysis and interpretation of data, drafting of the article, and final approval of the version to be published. Jean-Louis Blache, Jean Louis Bourgain and Catherine Grenier are responsible for revising the article critically for important intellectual content. Etienne Minvielle is the guarantor.

  • Accepted 24 September 2011
  • Published Online First 7 November 2011


Objective Implementation of a surgical checklist depends on many organisational factors and on socio-cultural patterns. The objective of this study was to identify barriers to effective implementation of a surgical checklist and to develop a best use strategy.

Setting 18 cancer centres in France.

Design The authors first assessed use compliance and completeness rates of the surgical checklist on a random sample of 80 surgical procedures performed under general or loco-regional anaesthesia in each of the 18 centres. They then developed a typology of the organisational and cultural barriers to effective checklist implementation and defined each barrier's contents using data from collective and semi-structured individual interviews of key staff, the results of an email questionnaire sent to the 18 centres, and direct observations over 20 h in two centres.

Results The study consisted of 1440 surgical procedures, 1299 checklists, and 28 578 items. The mean compliance rate was 90.2% (0, 100). The mean completion rate was 61% (0, 84). 11 barriers to effective checklist implementation were identified. Their incidence varied widely across centres. The main barriers were duplication of items within existing checklists (16/18 centres), poor communication between surgeon and anaesthetist (10/18), time spent completing the checklist for no perceived benefit, and lack of understanding and timing of item checks (9/18), ambiguity (8/18), unaccounted risks (7/18) and a time-honoured hierarchy (6/18).

Conclusions Several of the barriers to the successful implementation of the surgical checklist depended on organisational and cultural factors within each centre. The authors propose a strategy for change for checklist design, use and assessment, which could be used to construct a feedback loop for local team organisation and national initiatives.


  • Funding This project was supported by the National Federation of Cancer Centres and the French National Authority for Health (HAS).

  • Competing interests None.

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

  • Data sharing statement Data are available on request from the corresponding author.

This is an open-access article distributed under the terms of the Creative Commons Attribution Non-commercial License, which permits use, distribution, and reproduction in any medium, provided the original work is properly cited, the use is non commercial and is otherwise in compliance with the license. See: and

Open Access

Free sample

This recent issue is free to all users to allow everyone the opportunity to see the full scope and typical content of BMJ Quality & Safety.
View free sample issue >>

Email alerts

Don't forget to sign up for content alerts so you keep up to date with all the articles as they are published.


Navigate This Article