Patient safety

New scientific evidence supports WHO findings: a surgical safety checklist could save hundreds of thousands of lives

At least half a million deaths per year would be preventable with effective implementation of the WHO Surgical Safety Checklist worldwide. These results, obtained in the World Health Organization's 2007-2008 pilot study of its Surgical Safety Checklist have now been confirmed by new studies: the use of checklists significantly reduces surgical morbidity and mortality.

Published on 10 November in the New England Journal of Medicine (NEJM), a study conducted in the Netherlands from October 2007 to March 2009 shows that with the use of a checklist, surgery complications were reduced by more than one-third and deaths reduced by almost half (from 1.5% to 0.8%) in test hospitals compared to control hospitals. Checklist adherence was measured and tight correlations were found between the use of the checklist and achieving these results. Despite differences in research methodology and in the checklist itself, the results from the Netherlands study and the WHO pilot study are very similar, prompting NEJM editorialist Dr. John Birkmeyer to say this latest study 'should quiet the skeptics'.

In 2007 and 2008, a WHO pilot study involving hospitals in eight cities around the globe demonstrated that the use of a simple surgical checklist, developed by WHO, can lower the incidence of surgery-related deaths and complications by one third during major operations. Study limitations associated with this initial study raised some doubts as to whether these remarkable results can be repeated elsewhere by using a checklist tool - doubts which can be laid to rest now.

Hospitals currently using the WHO Surgical Safety Checklist have begun to collect local evidence that the Checklist makes a difference in surgical care. Recently Stanford University presented their findings at the 2010 American College of Surgeons Annual Clinical Congress held in Washington D.C. Researchers at Stanford found that the observed/expected mortality ratio declined from .88 in quarter one to .80 in quarter two with the use of a modified version of the WHO Surgical Safety Checklist. Moreover, they found that the use of the Checklist increased the frequency in which staff reported "Patient Safety Never Events" while the number of Patient Safety Never Events that were related to errors or complications decreased from 35.2% to 24.3%. Overall, the Checklist has not only impacted outcomes, but it has also improved communication among the surgical team, and thus quality of care.

Neither of the new studies tested the WHO Surgical Safety Checklist but both confirmed, in carefully controlled studies, the WHO pilot study findings that a thoughtfully constructed surgical safety checklist can achieve massive reductions in complications and death. The studies indicate that a checklist works because it is more than just a tick sheet: effective adoption generally requires local systems changes and commitment to teamwork for safety.

Dr Atul Gawande, External Lead of the Second Global Patient Safety Challenge on Safe Surgery in the WHO Patient Safety Programme, called the results of the new studies “remarkable validation. It is clear that the WHO Surgical Safety Checklist has already saved many thousands of lives since its introduction. We need to keep the pressure on health care facilities around the world to ensure adoption of the checklist so that hundreds of thousands more lives can be saved.”

In June 2008 the Safe Surgery Saves Lives Initiative released the WHO Surgical Safety Checklist globally and over the last two and a half years more than 3,900 hospitals representing more than 122 countries have registered as Safe Surgery Saves Lives Participating Hospitals signifying their intent to introduce the World Health Organization’s Surgical Safety Checklist in their operating theatres. Out of these 3,900 hospitals more than 1,800 hospitals have reported that they are routinely using the Checklist in at least one operating theatre. The commitment to improving surgical safety can also be seen at the governmental level with 25 countries committing resources to introduce the Checklist at a national scale.

In a press release issued on 11 November by the United Kingdom’s National Patient Safety Agency, Sir Liam Donaldson, Chairman of the WHO Patient Safety programme, said “Hospitals not using a surgical safety checklist are endangering patient safety. If I were to need an operation, I would want to be treated somewhere using a surgical checklist.”

There are 234 million operations performed globally each year. At least half a million deaths per year would be preventable with effective implementation of the WHO Surgical Safety Checklist worldwide. A surgical safety checklist has gone from a good idea recognized in a pilot study to a global standard of care, which already has saved many thousands of lives.

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