WHO safe surgery checklist reduces deaths and
21 January 2009
in eight cities around the globe have successfully demonstrated that the
use of a simple surgical checklist, developed by the World Health
Organization (WHO), during major operations can lower the incidence of
surgery-related deaths and complications by one third.
The study, led by the World Health Organization (WHO) and Dr Atul
Gawande of the Harvard School of Public Health, was published in the
online New England Journal of Medicine on January 14, 2009 and
will appear in the journal’s printed issue on January 29, 2009.
Developed by an international group made up of leading surgeons,
nurses, anaesthesiologists and patient safety experts, the WHO Surgical
Patient Safety Checklist was influenced by checklists used in the
airline industry to reduce the incidence of airline errors.
Launched in October 2007, eight hospitals were selected by WHO and
Harvard to pilot the Checklist as part of the WHO’s 'Safe Surgery Saves
The studies were undertaken in hospitals in each of the six WHO
regions, in both high and lower income settings — in Ifakara (Tanzania),
Manila (Philippines), New Delhi (India), Amman (Jordan), Seattle (United
States of America), Toronto (Canada), London (United Kingdom) and
Auckland (New Zealand).
The reductions in complications proved to be of equal magnitude in
high and lower income sites in the study. Analysis shows that the rate
of major complications following surgery fell from 11% in the baseline
period to 7% after introduction of the checklist, a reduction of one
third. Inpatient deaths following major operations fell by more than 40%
(from 1.5% to 0.8%).
"The concept of using a brief but comprehensive checklist is
surprisingly new to us in surgery. Not everyone on the operating teams
were happy to try it. But the results were unprecedented. And the teams
became strong supporters," said Dr Atul Gawande, main author of the
study and team leader for the development of the WHO surgical safety
“These findings have implications beyond surgery, suggesting that
checklists could increase the safety and reliability of care in numerous
medical fields,” Dr Gawande said. “The checklists must be short,
extremely simple, and carefully tested in the real world. But in
specialties ranging from cardiac care to paediatric care, they could
become as essential in daily medicine as the stethoscope."
"The immediate response to the checklist has been remarkable, and the
studies undertaken in the pilot hospitals are significant. They will
make a major contribution towards our goal of having 2500 hospitals
around the world using the safe surgery checklist by the end of this
year," said Sir Liam Donaldson, Chair of the WHO World Alliance for
Patient Safety and Chief Medical Officer for England.
“We know that many surgical complications are preventable,” said Dr
Bryce Taylor, University Health Network’s Surgeon in Chief, who
co-authored the study for the Toronto General Hospital. “With
approximately 234 million surgeries performed each year worldwide, we
owe it to our patients to look at every opportunity to prevent
complications during and after surgery.”
Studies in industrialized countries have found that major
complications occur in 3 to 16% of inpatient surgeries and a
perioperative death rates for inpatient surgery of 0.4 to 0.8%.
Inconsistent approaches to surgery can also lead to adverse events. For
example, there is strong evidence to support using antibiotics within
one hour prior to incision as a prophylaxis to reduce the possibility of
wound infections. Yet, surgical teams around the world are inconsistent
in their approaches.
The Checklist is intended to improve communications amongst members
of the surgical team during surgery and to increase the consistency in
using proven standards of surgical care in order to reduce preventable
complications and mortality.
At three critical points during surgery (prior to anaesthesia,
immediately prior to incision, and prior to patient exiting the
operating room), a member of the surgical team verbally confirms the
completion of each step for infection prophylaxis, anaesthesia safety
and other essential steps in surgery (eg confirming that the surgery
site is marked, counting the number of sponges and instruments used at
the end of surgery to ensure nothing has been left inside of the
Each pilot site implemented the Checklist in their operating rooms
and tracked changes in the rate of inpatient complication or death
within 30 days of surgery. To establish a baseline, data was collected
from a total of 3,733 patients before the implementation of the
Checklist and 3,955 patients after it was introduced.
Using the Checklist, the study found the following overall results:
- the rate of major complication in the study operating
rooms fell from 11.0% in the baseline period to 7.0% after the
introduction of the Checklist — a reduction of more than one-third;
- inpatient deaths following operation fell by over 40%
(from 1.5% to 0.8%) with the implementation of the Checklist; and
- similar reductions in complications were seen in both the
high income and lower income sites in the study, with rates falling
from 10.3% to 7.1 per cent and 11.7% to 6.8% respectively.
“The WHO agenda is a bold one, attempting to roll out a safety
checklist worldwide,” said Dr. Richard Reznick, University of Toronto’s
Chair of Surgery, UHN’s Vice President of Education and co-author of the
study. “These initial and very positive results will be a huge stimulus
for all countries to consider making this type of safety checklist
approach a regular aspect of surgical care.”
“Like an airline pilot, the surgeon is only one member of an entire
surgical team. Using the Checklist, we can improve communications during
surgery to make sure everyone is on the same page and to use proven
standards in every single operation to reduce the risks to patients,”
said Dr Taylor. “We are now using the surgical checklist at UHN’s
Toronto General, Toronto Western and Princess Margaret Hospitals to
ensure the highest possible standards in our operating rooms.”
The WHO Safe Surgery Saves Lives initiative:
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