Table 2

Implementation studies of the WHO Surgical Safety checklist

Author [year]Description of Patient Safety Practice (PSP)Study designTheory or logic modelDescription of organisationSafety context
Sewell et al [2011]242008 WHO surgical checklist, unmodifiedBefore and after study, comparing pre-training period to post-training‘The underlying philosophy of the checklist is that a true team approach with good communication between operating room team members is safer and more efficient than a hierarchical system that relies on individuals’A UK hospital, orthopaedic operations. 28% of operations were urgent, and 77% involved general anaesthesiaPre-training period February–May 2009 (480 operations). During this period: correct checklist use was 8%, and 47% thought it improved team communication; pre-training staff perceptions: 55% thought it caused an unnecessary time delay, 28% thought it improved patient safety, 47% thought it improved team communication and teamwork, 64% would want the checklist used if they were having an operation
Helmio et al [2011]552008 WHO surgical checklist. No specialty-related changes, but some ‘minor changes.’ Checklist included in publication; modifications did not exclude any itemsBefore and after study‘The idea of the checklist is to be an add-on security tool for the defined safety standard’Finland, otorhinolaryngology head and neck surgery ORs. 747 operations in the 2-month study periods combined. All subgroups of otorhinolaryngology head and neck surgery were includedOne-month pre-implementation period in May 2009 (304 operations): 17% were urgent operations; 24% were on children; 16% were local anaesthesia. Before implementation: knowledge of OR-teams’ names and roles ranged from 61% to 92%. Discussing risks was 24%. Postop instructions recorded 7–84%. Successful communication 79–93%
Conley et al [2011]282008 WHO surgical checklist, unmodifiedCase seriesNone explicitly statedFive Washington State hospitals. Two hospitals had <10 ORs, one had 10–20 and two had >20. Two urban, two suburban and one ruralNothing reported about pre-existing safety culture. The Vice President for Patient Safety at the Washington State Hospital Association provided ‘significant assistance’. Checklist introduction December 2008 to January 2009. Interviews conducted September–December 2009. One of the five hospitals had a recent wrong-site incision that motivated surgical staff and ‘opened people's eyes to the need for ongoing patient safety efforts’
Bell and Pontin [2010]56, Bell572008 WHO checklist adapted different for different surgical specialties. Checklist not included in publicationCase series‘Without a doubt, the checklist works best when all staff members are engaged’Large two-hospital trust in the UK with 10 000 staff and 850 000 patients annuallyNothing about pre-existing safety culture. To prepare for the checklist, they set up a Patient Safety Working Group
Sparkes and Rylah [2010]582008 WHO checklist locally adapted. Checklist included in publication; modifications did not exclude any itemsCase seriesDiscussed various ways a checklist could enhance safety, including teamwork and effective communicationTeaching hospital in the UK with 29 ORs in five locations performing specialised complex surgeryNR
Royal Bolton [2010]362008 WHO checklist, unmodified. Local adaptation of it was considered but ultimately not doneCase seriesImprove patient safety by enhancing teamwork and communicationTrust in the UK with eight ORsPrior to the checklist, the trust already had a core group of patient safety experts assembled; this group met to discuss how to introduce the checklist. They examined the previous year's 41 safety incidents and all were ‘found to be avoidable had the checklist been in use’
Vats et al [2010]262008 WHO surgical checklist adapted for England and Wales. Checklist included in publication; modifications did not exclude any itemsCase series‘the checklist ensures that critical tasks are carried out and that the team is adequately prepared for the operation’UK academic hospitalNothing reported about pre-existing safety culture. Piloted March–September 2008 at a London hospital in 58% of operations (424/729) among the two ORs selected (one for trauma/orthopaedics OR, the other for GI/GYN)
Kearns et al [2011]25WHO surgical checklist, version NR. Some obstetric-specific checks had been added, but the list of revisions was not reported. Checklist not included in publicationBefore and after study‘Checklists may be used to improve patient safety by ensuring that all elements of a practice are instituted for each new clinical event’UK study in obstetrics ORs. Tertiary referral obstetric centre with ∼6400 deliveries per yearBefore introducing the checklist, they measured staff attitudes, preserving respondent anonymity: 30% ‘felt familiar’ with others in the OR, 81% felt communication could improve, 85% felt that in elective cases the checklist would be useful, 53% felt that in emergency cases the checklist would be inconvenient
Norton and Rangel [2010]592008 WHO checklist modified for paediatric operations and also to meet the 2009 Joint Commission Universal Protocol. Checklist included in publication. Removed the following three items from the WHO checklist: pulse oximetry, difficult airway, anticipated blood lossCase seriesChecklist can help to reduce breakdowns in communication, ineffective teamwork and lack of compliance with process measuresChildren's hospital in the USA performing numerous types of paediatric surgeryAt this hospital they had been building a quality infrastructure for 5 years prior, and had already implemented the Universal Protocol
Styer et al [2011]292008 WHO checklist modified and implemented as hospital policy. Selected modifications listed. Checklist not included in publicationQualitative descriptionImplementing checklist using a PDSA cycle stepwise approach leads to smoother transition and sustained outcomesTeaching hospital in the USA with 44 ORs‘This initiative … was introduced to see how the checklist might fit within our hospital culture’
Bittle [2011]602008 WHO checklist adapted for individual hospital. Checklist not included in publicationQualitative descriptionChecklists ‘ensure there is adherence to proven standards or care’Large city hospital in New ZealandQuality service improvement team
Yuan [2012]142008 WHO checklist modified for local practice. Checklist included in publicationBefore and after studyChecklists are an inexpensive and feasible way to potentially improve quality of surgical care in ‘resource-limited settings’Two hospitals (each with 2 ORs) in Monrovia, Liberia. Hospital 1 (150-bed primary community hospital), hospital 2 (200-bed, government referral hospital)Liberia is rebuilding health system infrastructure after 14 years of conflict. Checklist implementation was a collaboration with the Ministry of Health and Social Welfare in Liberia to characterise its impact in low resource context
Kasatpibal et al [2012]342008 WHO checklist modified and translated. Hair removal added to checklist. Other modifications not described. Checklist not included in publicationCase seriesChecklists may reduce preventable adverse surgical events, but may be difficult or inappropriate to implement in a developing countryUniversity hospital in northern Thailand (1400 beds, 21 877 operations annually)Average rate of surgical site infection in Thailand is 1.7%
Bohmer et al [2012]302008 WHO checklist modified. Checklist included in publicationBefore and afterChecklists may improve staff's perception of patient safety and job satisfactionInstitute for research in Operative Medicine of the University of Witten/HerdeckeNR
Fourcade et al [2012]272008 WHO checklist modified. Checklist included in publicationCase series
1. Random sample of 80 surgeries from each centre performed over 18-day interval.
2. Interviews and surveys of participating staff
Checklists may improve surgical outcomes, but face barriers to efficient implementation18 cancer centres in FranceThe French National Authority for Health introduced a modified checklist as mandatory. Implemented by French National Federation of Cancer Centres along with research team from Coordination for Measuring Performance and Assuring Quality of Hospitals, Institut Gustave Roussy
Perez-Guisado et al [2012]622008 WHO checklist. Checklist included in publicationDescriptive cross-sectional study of plastics, reconstructive surgical proceduresChecklist ‘involves new philosophy of organisation that is easier to achieve in health workers with lower hierarchy’ (ie, nurses, surgeon residents)Reina Sofia Hospital (1684 surgeries)NR
van Klei et al [2012]332008 WHO checklist modified. Checklist available in online supplementary materialBefore and afterChecklists enhance teamwork and improve handovers decreased avoidable errors and complicationsUniversity Medical centre Utrecht (The Netherlands)Checklist implemented in accordance with mandatory policy by the Dutch Health Care Inspectorate
Takala et al [2011]632008 WHO checklist, modified. Checklist available in appendixBefore and after‘Checklist would improve awareness of safety-related issues and the fluency of operations as well as communication during surgery’Four university teaching hospitals in FinlandPilot study to investigate usefulness of the checklist in a variety of surgical specialties to inform development of a national checklist
Truran et al [2011]642008 WHO checklist, modified. Checklist not includedBefore and afterThe checklist may improve compliance with venous thromboembolism prophylaxis guidelinesHospitals in the UKNR
Vogts et al [2011]322008 WHO checklist, modified. Checklist included in appendixCase seriesChecklists ‘promote communication and teamwork within the OR’Auckland City Hospital, New ZealandChecklist implemented 2 years prior
Askarian et al [2011]352008 WHO checklist. No modifications noted, checklist not included in publicationBefore and afterChecklist may improve patient safety by reducing surgical complicationsReferral educational hospital in Shiraz, southern Iran (374 beds, 6 ORs)The Iranian Ministry of Health, Treatment and Medical Education approved nationwide use of checklist in 2009
Levy et al [2012]312008 WHO checklist modified. Modified checklist not included in publicationCase seriesLow fidelity of checklist execution may be a barrier to improving health outcomesAcademic tertiary care children's hospital (Texas, USA)Checklist compliance reported at 100%, but fidelity of checklist use is unclear
Helmio et al [2012]15WHO checklist (unclear if modified). Checklist not included in publicationCase series‘This checklist has reduced complications and deaths significantly’Otorhinolaryngology department in four Finnish hospitalsChecklist implemented in these hospitals during WHO pilot project in 2009
  • GI, gastrointestinal; GYN, gynaecology; NR, not reported; OR, operating room; PDSA, plan–do–study–act.