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Safety checklist compliance and a false sense of safety: new directions for research
  1. Christofer Rydenfält1,
  2. Åsa Ek1,
  3. 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}

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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 …

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  • Contributors All authors contributed to the development of the ideas presented in this publication. CR was mainly responsible for the drafting of the manuscript with the other authors providing critical input, suggestions and feedback.

  • Funding The Gorthon Foundation.

  • Competing interests None.

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