Patient safety

Safe Surgery Saves Lives Frequently Asked Questions


Implementation FAQ

Q1: My hospital is quite large with many operating rooms. How can I implement a checklist in this environment?

A: The key to successful implementation is to start small. Start with a single operating room on one day and see how it works. This will guide you to strategies for altering the checklist to fit your needs, as well as identify potential barriers to adaptation.

Q2: We already do these things. Why should we use a checklist?

A: While most or all of the items on the checklist may already be done at your hospital, we have found that in most hospitals there are opportunities for improvement in consistency. The checklist helps ensure that important safety steps are followed for each and every operation.

Q3: Our surgical teams don’t want to use the WHO Surgical Safety Checklist unless they can change a few of the elements. Is it okay to make changes to the Checklist?

A: Yes, the checklist was not intended to be comprehensive, and we encourage modifications for local use. We understand that the Checklist, while intended to be universally applicable, is not always a perfect fit for all institutions. Modifications can be made to include items that are deemed essential. However, please avoid making the checklist too comprehensive. The more items added to it, the more difficult it will be to successfully implement. Please refer to the Starter Kit for Implementing the Surgical Safety Checklist and the Checklist Adaptation Guide for recommendations on modifying the Checklist.

Q4: My team often stays together for the whole day. Must we introduce ourselves before every surgery?

A: The most critical time for introductions is at the beginning of an operative day. There is no need to repeat introductions if they have already been made. However, if new members join a room, they should introduce themselves as should every member of the team present. Even if everyone knows each other, introductions are important as they serve to reinforce team communication (and can help avoid embarrassment at having to ask someone’s name with whom one has been working for a prolonged period of time!).

Q5: Who should be in charge of running the checklist?

A: Although every member of the operating team – surgeons, anesthetists, nurses, technicians, and other operating room personnel – is involved in its execution, a single person should be responsible for leading the discussion of all components of the checklist and is essential for its success. This will often be a circulating nurse, but it can be any clinician or healthcare professional participating in the operation. This individual can and should prevent the team from progressing to the next phase of the operation until each step is satisfactorily addressed.

Q6: Should we memorize the checklist?

A: No. Checklists are created to avoid the pitfalls of memorization and omissions that occur when standardized processes are not clearly written and defined. The goal of the Checklist is to help ensure that teams consistently follow a few critical safety steps and thereby minimize the most common avoidable risks endangering the lives and well-being of surgical patients.

Q7: Do we need to actually check the boxes on the checklist?

A: No. The checklist was not designed as an audit tool; however, an institution can use it as such if this is likely to improve the safety of surgical care. In addition to a piece of paper, the checklist can be converted into a poster, incorporated into electronic records, or laminated for reuse.

Q8: What’s in it for me?

A: By implementing the checklist, you can help to save patients’ lives and decrease complications, be on the forefront of the surgical safety movement, and be a leader in your hospital.

Q9: Our budget is very tight. How can we implement the checklist?

A: Using the checklist requires very minimal resource commitment. Reproduction and distribution of the checklist is the main financial cost. There is some need for personnel commitment at the beginning, but once the checklist has spread it should sustain itself.

Q10: How much does it cost to implement the checklist?

A: The checklist is free to download, but will require input of human resources in order to implement it hospital-wide. Please read the toolkit, available on the website, to get a sense for the level of commitment this venture will require. Many of the elements of the checklist, such as a verification of patient’s identification, require no money to implement and could save the hospital thousands of dollars by preventing surgical mishaps. Other items on the checklist, such as the use of antibiotics from 0 to 60 minutes prior to incision, make sure that resources that hospitals already have are used to their fullest potential.

Q11: We are already very busy in the operating room. Isn’t this just one more task using up valuable time?

A: Once the checklist has become familiar to the operating teams, it requires very little extra time to perform. Most of the steps are incorporated into existing workflow and the remainder will add only one or two minutes to the OR time. However, the checklist can also save time be ensuring better coordination between the teams, minimizing slowdowns for tasks like retrieval of additional equipment.

Q12: While there is enthusiasm amongst some clinicians for the checklist, there are others who do not see the value of this initiative. Can we still use the checklist?

A: Yes. Implementation should always begin with the most enthusiastic. Go after the “low hanging fruit,” those who are interested in improvement. The checklist can be implemented by an individual clinician in cases in which he or she participates, a selected service or operating room suite at a hospital, or on a hospital-wide or even system-wide basis. Focus energy on those areas and individuals who are receptive to the idea at first and as they become accustomed to the checklist and its benefits, they will help it spread to their peers.

Q13: We are interested in improving our hospital’s performance in some perioperative measures not included on the checklist. How can we do this?

A: The checklist, while intended to be universally applicable, is not always a perfect fit for all institutions. Modifications can be made to include items that are deemed essential. However, we would caution against making the checklist too comprehensive. The more items added to it, the more difficult it will be to successfully implement.

Q14: How can I convince administrators/clinicians that this is worth doing?

A: As part of our Starter Kit, we’ve included a section called, “Questions for Hospitals to Answer Prior to Implementing the Checklist.” Having the baseline data this form is designed to collect, will enable you to demonstrate to the administration any weaknesses in the perioperative process and later see how far you have come with regard to outcome and process measures. We highly recommend not simply using the checklist, but measuring how that use changes the way surgery is practiced.

Q15: I have additional questions not covered by the FAQ. Can I speak to someone?

A: We are currently setting up a network of mentors who have successfully implemented the checklist. Please visit our website again soon for updated information. In the mean time, please address all questions and concerns to safesurgery@hsph.harvard.edu.