BMJ Qual Saf 22:940-947 doi:10.1136/bmjqs-2012-001749
  • Original research

A prospective, observational study of the effects of implementation strategy on compliance with a surgical safety checklist

  1. S J Mitchell1,3
  1. 1Department of Anaesthesiology, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
  2. 2Department of Surgery, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
  3. 3Auckland City Hospital, Auckland, New Zealand
  1. Correspondence to Associate Professor Simon Mitchell, Department of Anaesthesiology, University of Auckland, L12, Auckland City Hospital, 2 Park Road, Grafton, Auckland 1023, New Zealand; sj.mitchell{at}
  • Received 12 December 2012
  • Revised 12 May 2013
  • Accepted 15 June 2013
  • Published Online First 9 July 2013


Background The reported benefits of using the WHO Surgical Safety Checklist (SSC) are likely to depend on compliance with its correct use. Compliance with SSC administration in centres that have introduced the checklist under a research protocol may differ from centres where the SSC is introduced independently.

Objective To compare compliance with SSC administration at an original WHO pilot study centre (Hospital 1) with that at a similar neighbouring hospital (Hospital 2) that independently integrated the SSC with pre-existing practice.

Methods This was a prospective, observational study. One hundred operations were observed at each hospital. We recorded: compliance with administration of SSC domains (Sign In, Time Out and Sign Out) and individual domain items; timing of domain administration; and operating room team engagement during administration.

Results Domain compliance at Hospital 1 and Hospital 2, respectively, was: 96% and 31% (p<0.0005) for Sign In; 99% and 48% (p<0.0005) for Time Out and 22% and 9% (p=0.008) for Sign Out. Engagement of two or more teams during Sign In and Time Out occurred more frequently at Hospital 2 than at Hospital 1.

Discussion Compliance with administration of SSC domains was lower at Hospital 2 which introduced the SSC outside the context of a strict study protocol. This finding mandates caution in extrapolation of benefits identified in SSC studies to non-study hospitals. Staff engagement was better at Hospital 2 where checklist administration leadership is strategically shared among anaesthetic, surgical and nursing team members as compared with exclusive nursing leadership at Hospital 1.

Study registry number Australian and New Zealand Clinical Trials Registry: Ref: ACTRN12612000135819,

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