BMJ Qual Saf 23:183-186 doi:10.1136/bmjqs-2013-002168
  • Viewpoint

Safety checklist compliance and a false sense of safety: new directions for research

  1. Per Anders Larsson2
  1. 1Department of Design Sciences, Lund University, Lund, Sweden
  2. 2Helsingborg Hospital, Helsingborg, Sweden
  1. Correspondence to Christofer Rydenfält, Department of Design Sciences, Faculty of Engineering, P.O. Box 118, Lund SE-221 00, Sweden; christofer.rydenfalt{at}
  • Received 22 May 2013
  • Revised 15 August 2013
  • Accepted 12 September 2013
  • Published Online First 3 October 2013


In recent years, checklists to improve patient safety have gained considerable support.1–,4 The most well-known checklist introduced for this purpose is probably the WHO surgical safety checklist.5

The WHO checklist consists of three parts: (1) the sign in before anaesthesia, (2) the timeout before incision and (3) the sign out before the patient leaves the operating room. Previous studies show that the WHO checklist reduces both complications from care and the 30-day mortality rate.2 ,3 These results are supported by other studies using similar checklist methodologies.1 ,6 Initially, the evaluation focus was on the effects of checklists using measures such as complications and mortality. Recently, though, researchers have started to pay attention to the actual usage of checklists in practice by investigating compliance.7–,10 The compliance rate reported in these studies could at best be considered as moderate. Rydenfält et al8 report a compliance of the timeout part of 54%, despite timeouts being initiated in 96% of the cases studied. In the study by Cullati et al,7 the mean percentage of validated checklist items in the timeout was 50% and in the sign out 41%.

Despite previous studies showing that both complications and 30-day mortality decreased,2 ,3 this raises the question: do safety checklists used with this level of compliance really make practice safer? Could it even be that the lack of compliance actually introduces new risks not present before? In the following viewpoint, we investigate the latter question from a safety science perspective to introduce new perspectives on the usage and implementation of checklists in healthcare and outline suitable directions for future research.

Theoretical framework

The checklist as a defence against failure

The main idea with checklists such as the WHO surgical safety checklist is to serve as a defence or barrier between …

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