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Table of Contents
Year : 2018  |  Volume : 34  |  Issue : 1  |  Page : 7-10

WHO safe surgery checklist: Barriers to universal acceptance

Department of Anesthesia and Intensive Care, Post Graduate Institute of Medical Education and Research, Chandigarh, India

Date of Web Publication15-Mar-2018

Correspondence Address:
Divya Jain
H.No-3034, Sector 21-D, Chandigarh - 160 022
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/joacp.JOACP_307_16

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Development of the Safe Surgery Checklist is an initiative taken by the World Health Organization (WHO) with an aim to reduce the complication rates during the surgical process. Despite gross reduction in the infection rate and morbidity following adoption of the checklist, many health-care providers are hesitant in implementing it in their everyday practice. In this article, we would like to highlight the hurdles in adoption of the WHO Surgical Checklist and measures that can be taken to overcome them.

Keywords: Adoption barriers, Safe surgery save lives, World Health Organization safe surgery checklist

How to cite this article:
Jain D, Sharma R, Reddy S. WHO safe surgery checklist: Barriers to universal acceptance. J Anaesthesiol Clin Pharmacol 2018;34:7-10

How to cite this URL:
Jain D, Sharma R, Reddy S. WHO safe surgery checklist: Barriers to universal acceptance. J Anaesthesiol Clin Pharmacol [serial online] 2018 [cited 2021 Jul 26];34:7-10. Available from:

  Introduction Top

“Safe Surgery Save Lives” was initiated by the World Health Organization (WHO) in 2007 with an aim to reduce the number of surgical deaths across the world.[1] To accomplish the target of improving patient safety without additional resource utilization, the WHO surgical safety checklist was introduced in 2009.[2]

The WHO 19-item checklist program [Annexure 1] emphasizes on performing safety checks and good team communication at various stages in the perioperative period to reduce the complication rates during the surgical process. It has played a pivotal role in decreasing the surgical morbidity and mortality globally. Despite substantial evidence advocating the need of the WHO checklist in reducing the infection rate and morbidity, the hesitancy among many health-care providers to implement it in everyday practice is a matter of concern. In this article, we would like to highlight the barriers in universal adoption and implementation of the WHO Surgical Checklist and measures that can be taken to overcome these hurdles.

  Why Do We Need Checklist? Top

A systematic review suggested that in the hospital, the majority of the adverse events take place in the operating theater and 43% of these mishaps were preventable using the current standards of care.[3] According to one survey, 234 million people are operated on each year, out of which one million die because of complication and among all at least half of these complications are avoidable.[4] Data from the developed nations revealed the complication rate of 3%–16% in inpatient surgical procedures, and the death rate was 0.4%–0.8%[5]

Despite this data, the need for surgical safety is not recognized as a significant health problem, especially in middle- and low-income group countries where the resources are limited. Furthermore, the reliability and timely issuance of basic routine steps to decrease infection-related complications such as administration of antibiotic remains doubtful.

A Checklist helps ensure that teams consistently follow a few critical safety steps, and thereby minimize the avoidable risks endangering the lives of surgical patients.[6],[7],[8] The WHO Surgical Checklist is intended to give surgical teams a simple and efficient set of priority checks to ensure patient safety, effective teamwork, and communication in every operation performed.

  Effectiveness of Checklist: Evidence in Support Top

Following its inception in 2008, the WHO Checklist was piloted in eight hospitals globally including both developed and developing nations. The initial results of implementation of the WHO Checklist in these hospitals showed a decrease in surgical site infections from 6.2% to 3.4% and decrease in death rate from 1.5% to 0.8%. About 79% of the staff involved thought it easy to use, 79% thought it improved care, 84% thought it improved communication, and 78% thought it reduced errors.[9] Greater benefit from the adoption of WHO checklist was seen in low- and middle-income group countries compared to the high-income group countries.

The initial results generated an awareness about surgical safety and were followed by reports about significant reduction in surgical complications all over the globe.[10],[11],[12],[13],[14],[15],[16],[17],[18],[19],[20] The Netherlands Surgical Patient Safety System found a significant reduction in in-hospital mortality (1.5%–0.8%) and in overall complications (27.3–16.7/100) after implementation of a comprehensive surgical checklist.[10] Introduction of the checklist in the hospitals in Liberia was associated with significant (P< 0.05) improvements in terms of overall surgical processes and surgical outcome.[11]

Recent meta-analysis of seven trials on the effect of surgical checklist on complication rate and postoperative mortality found the evidence highly suggestive of a reduction in postoperative complications and mortality following implementation of the WHO surgical checklist.[20]

The maiden study from India reported reduction in mortality and improved postoperative outcomes following implementation of the WHO Surgical Safety Checklist in a tertiary care hospital.[21]

  Who Checklist: Why We Do not Follow? Top

Adoption of a new concept into practice is always a challenge. There would be a few who would be fast at imbibing the concept, whereas there would be some who would be reluctant. The effective implementation requires not only technical change but also cultural or an organizational change. Fourcade et al. identified eleven organizational barriers to implementation such as poor communication between the anesthetic and surgeon, lack of leadership, inappropriate timing for checking an item, time taken up by checklist completion, and difficulty in identifying the role and responsibility of each staff member.[22]

Challenges or Hurdles in implementation


The hierarchy among operation theater personnel acts as a major hindrance in successful implementation of the checklist. The lead taken over by the staff nurse during the sign in phase is generally not well taken by the surgeon or the anesthesiologist. Checklists can be completed thoroughly only if the surgeon and the anesthesiologist are supportive.[23] Inculcating the team dynamics through proper training can help to overcome this barrier.


The surgeon and staff exposed to checklist programs resent the delay before the start of surgery and interruption to workflow, especially during the sign phase of the checklist. The importance of these delays to prevent any avoidable errors for the safety of the patient needs to be emphasized. In a study conducted in UK clearly showed that Safe Surgical Checklists do not have any significant impact on theater start time.[24]

Increase the workload

Paramedical staff working in the operation theaters with huge turnover of cases, consider checklist as an unnecessary interruption of their streamlined routine work and addition to the burden of the already overburdened staff.

Lower applicability in emergency situations

There is often reluctance to follow the 19-item checklist during urgent or emergent surgeries. Contrary to the common belief of inapplicability of checklist in these setting, there is a greater need for safety checks due to high error rate in the emergency departments. Implementation of checklist in a setting of urgent operations showed a 36% decrease in complication rate from 18.7% to 11.7% and 62% reduction in mortality from 3.7% to 1.4%.[19]

Raises the anxiety in awake patient

There have been concerns that patient might become restless or anxious hearing the checklist protocol, especially if deficiencies in preparation of the operation theater are revealed. However, these issues can be prevented by appraising the patient about the importance of checklist before surgery. In a survey, 68% agreed that they would feel comfortable with a nurse caring checklist.[25] Beside all, when patients are aware of the checks before performed this does not provoke anxiety.

Tick-box exercise

Accountability of each team member during the checklist protocol has a crucial role in the success of the checklist. The most common lacunae in following this program is that most of the healthcare provider are not perceiving it as an important tool in their armamentarium to ensure patient safety by better teamwork and communication, rather considering it a tick the box exercise.[26]

Sign out time most common barrier

Practically thinking, “Sign out” time is one of the biggest barriers in the implementation of the checklist. The reason being the varied timeout between surgeon and anesthetist. At the end of the surgery, surgeon leaves the operation theater to take a break before next case or dictate notes, the nurse staff is occupied with packing and labeling of the samples, and for anesthesiologist, it is most critical time. As the result, the key concerns for the recovery and postoperative management of the patient are often not discussed by the operative team.

Overcoming the problem

There is a need to identify the barriers in implementation and then develop strategies to overcome them.

Developing local champions

To float a new idea, we need to identify the people who are enthusiastic. The initial team should be formulated with these local champions. Over time, seeing the intervention being used with positive results, people who are initially reluctant would drop their objections and start to adopt it in their practice. Owing to the strong association of age and experience with the usage of WHO checklist,[27] leadership and championing by senior staff might help in the successful implementation of the checklist.[28]


Before implementing, a training programs led by the local champions can help in the successful implementation. The workshops on how to conduct a checklist not only makes the team members aware of their role during checklist protocol but also inculcates the team spirit. In a study conducted at Children's Hospital in Brasov, 40 surgeries were observed over 10 days to record the compliance of the WHO surgical safety checklist to identify the barriers in adoption. They highlighted the need for training of staff to improve knowledge and compliance days for the successful implementation of the Surgical Safety Checklist.[29]

Start small

A more practical form is to implement the checklist in one or two operation theaters. The results obtained can act as a catalyst for its future spread.

Straight forward format

Measures should be taken for making checklist more of a straightforward, in a more participating format involving all theatre personnel rather making it one person job. One of the constrains is lack of encouraging data and other evidence of avoiding patient complications which do not provide evidence of fidelity in implementing checklist.

Local adjustment and adaptation

To increase the feasibility and usefulness of checklist, emphasis is on the importance of local adjustment and adaptation.[2],[30],[31]

Regular audits

Regular audits help to monitor the progress of a program. The results and complications should be discussed so that an early solution can be sought. The feedback obtained from these audits can help in the success of the program.[2],[30],[31]

  Conclusion Top

The WHO Surgical Checklist is a promising tool to reduce the surgical complications worldwide. The surgeons, anesthetists, and the paramedical staff need to work together to overcome the sociocultural and organizational hurdles to ensure successful implementation of the WHO surgical checklist.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

World Health Organization. Safe Surgery Saves Lives 2008. Available from: [Last accessed on 2015 Oct 16].  Back to cited text no. 1
WHO Surgical Safety Checklist and Implementation Manual. Available from: [Last accessed on 2015 Oct 10].  Back to cited text no. 2
de Vries EN, Ramrattan MA, Smorenburg SM, Gouma DJ, Boermeester MA. The incidence and nature of in-hospital adverse events: A systematic review. Qual Saf Health Care 2008;17:216-23.  Back to cited text no. 3
Borchard A, Schwappach DL, Barbir A, Bezzola P. A systematic review of the effectiveness, compliance, and critical factors for implementation of safety checklists in surgery. Ann Surg 2012;256:925-33.  Back to cited text no. 4
Bosk CL, Dixon-Woods M, Goeschel CA, Pronovost PJ. Reality check for checklists. Lancet 2009;374:444-5.  Back to cited text no. 5
Walker IA, Reshamwalla S, Wilson IH. Surgical safety checklists: Do they improve outcomes? Br J Anaesth 2012;109:47-54.  Back to cited text no. 6
Lingard L, Regehr G, Orser B, Reznick R, Baker GR, Doran D,et al. Evaluation of a preoperative checklist and team briefing among surgeons, nurses, and anesthesiologists to reduce failures in communication. Arch Surg 2008;143:12-7.  Back to cited text no. 7
Lingard L, Whyte S, Espin S, Baker GR, Orser B, Doran D,et al. Towards safer interprofessional communication: Constructing a model of “utility” from preoperative team briefings. J Interprof Care 2006;20:471-83.  Back to cited text no. 8
Haynes AB, Weiser TG, Berry WR, Lipsitz SR, Breizat AH, Dellinger EP,et al. A surgical safety checklist to reduce morbidity and mortality in a global population. N Engl J Med 2009;360:491-9.  Back to cited text no. 9
de Vries EN, Prins HA, Crolla RM, den Outer AJ, van Andel G, van Helden SH,et al. Effect of a comprehensive surgical safety system on patient outcomes. N Engl J Med 2010;363:1928-37.  Back to cited text no. 10
Yuan CT, Walsh D, Tomarken JL, Alpern R, Shakpeh J, Bradley EH,et al. Incorporating the World Health Organization Surgical Safety Checklist into practice at two hospitals in Liberia. Jt Comm J Qual Patient Saf 2012;38:254-60.  Back to cited text no. 11
Askarian M, Kouchak F, Palenik CJ. Effect of surgical safety checklists on postoperative morbidity and mortality rates, Shiraz, Faghihy Hospital, a 1-year study. Qual Manag Health Care 2011;20:293-7.  Back to cited text no. 12
Haugen AS, Søfteland E, Almeland SK, Sevdalis N, Vonen B, Eide GE,et al. Effect of the World Health Organization checklist on patient outcomes: A stepped wedge cluster randomized controlled trial. Ann Surg 2015;261:821-8.  Back to cited text no. 13
Takala RS, Pauniaho SL, Kotkansalo A, Helmiö P, Blomgren K, Helminen M,et al. A pilot study of the implementation of WHO surgical checklist in Finland: Improvements in activities and communication. Acta Anaesthesiol Scand 2011;55:1206-14.  Back to cited text no. 14
Böhmer AB, Wappler F, Tinschmann T, Kindermann P, Rixen D, Bellendir M,et al. The implementation of a perioperative checklist increases patients' perioperative safety and staff satisfaction. Acta Anaesthesiol Scand 2012;56:332-8.  Back to cited text no. 15
Truran P, Critchley RJ, Gilliam A. Does using the WHO surgical checklist improve compliance to venous thromboembolism prophylaxis guidelines? Surgeon 2011;9:309-11.  Back to cited text no. 16
Berrisford RG, Wilson IH, Davidge M, Sanders D. Surgical time out checklist with debriefing and multidisciplinary feedback improves venous thromboembolism prophylaxis in thoracic surgery: A prospective audit. Eur J Cardiothorac Surg 2012;41:1326-9.  Back to cited text no. 17
van Klei WA, Hoff RG, van Aarnhem EE, Simmermacher RK, Regli LP, Kappen TH,et al. Effects of the introduction of the WHO “Surgical Safety Checklist” on in-hospital mortality: A cohort study. Ann Surg 2012;255:44-9.  Back to cited text no. 18
Weiser TG, Haynes AB, Dziekan G, Berry WR, Lipsitz SR, Gawande AA,et al. Effect of a 19-item surgical safety checklist during urgent operations in a global patient population. Ann Surg 2010;251:976-80.  Back to cited text no. 19
Bergs J, Hellings J, Cleemput I, Zurel Ö, De Troyer V, Van Hiel M,et al. Systematic review and meta-analysis of the effect of the World Health Organization surgical safety checklist on postoperative complications. Br J Surg 2014;101:150-8.  Back to cited text no. 20
Chaudhary N, Varma V, Kapoor S, Mehta N, Kumaran V, Nundy S,et al. Implementation of a surgical safety checklist and postoperative outcomes: A prospective randomized controlled study. J Gastrointest Surg 2015;19:935-42.  Back to cited text no. 21
Fourcade A, Blache JL, Grenier C, Bourgain JL, Minvielle E. Barriers to staff adoption of a surgical safety checklist. BMJ Qual Saf 2012;21:191-7.  Back to cited text no. 22
Vats A, Vincent CA, Nagpal K, Davies RW, Darzi A, Moorthy K,et al. Practical challenges of introducing WHO surgical checklist: UK pilot experience. BMJ 2010;340:b5433.  Back to cited text no. 23
Vats A, Marbaniang M, Gupta P. Does the safe surgery check list delay the start of the theatres? Eur J Anaesthesiol 2011;28:11.  Back to cited text no. 24
Kearns RJ, Uppal V, Bonner J, Robertson J, Daniel M, McGrady EM,et al. The introduction of a surgical safety checklist in a tertiary referral obstetric centre. BMJ Qual Saf 2011;20:818-22.  Back to cited text no. 25
Sewell M, Adebibe M, Jayakumar P, Jowett C, Kong K, Vemulapalli K,et al. Use of the WHO surgical safety checklist in trauma and orthopaedic patients. Int Orthop 2011;35:897-901.  Back to cited text no. 26
Vohra RS, Cowley JB, Bhasin N, Barakat HM, Gough MJ, al. Attitudes towards the surgical safety checklist and factors associated with its use: A global survey of frontline medical professionals. Ann Med Surg (Lond) 2015;4:119-23.  Back to cited text no. 27
Aveling EL, McCulloch P, Dixon-Woods M. A qualitative study comparing experiences of the surgical safety checklist in hospitals in high-income and low-income countries. BMJ Open 2013;3:e003039.  Back to cited text no. 28
McGinlay D, Moore D, Mironescu A. A prospective observational assessment of Surgical Safety Checklist use in Brasov Children's Hospital, barriers to implementation and methods to improve compliance. Rom J Anaesth Int Care 2015;22:111.  Back to cited text no. 29
Sendlhofer G, Mosbacher N, Karina L, Kober B, Jantscher L, Berghold A,et al. Implementation of a surgical safety checklist: Interventions to optimize the process and hints to increase compliance. PLoS One 2015;10:e0116926.  Back to cited text no. 30
Russ SJ, Sevdalis N, Moorthy K, Mayer EK, Rout S, Caris J,et al. A qualitative evaluation of the barriers and facilitators toward implementation of the WHO surgical safety checklist across hospitals in England: Lessons from the “Surgical Checklist Implementation Project”. Ann Surg 2015;261:81-91.  Back to cited text no. 31


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