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Year : 2017  |  Volume : 2  |  Issue : 2  |  Page : 54-55

Surgical safety checklist: Outcomes and policing mechanics

1 Department of Surgery, Fatima Memorial Hospital, Lahore, Pakistan
2 Department of Anatomic Sciences, Shalamar Medical and Dental College, Shalamar Hospital, Lahore, Pakistan

Date of Submission16-Jan-2017
Date of Acceptance05-May-2017
Date of Web Publication22-Jun-2017

Correspondence Address:
Ahsan Zil-E-Ali
Department of Surgery, Fatima Memorial Hospital, Lahore 54000
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ts.ts_1_17

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How to cite this article:
Zil-E-Ali A, Riaz A. Surgical safety checklist: Outcomes and policing mechanics. Transl Surg 2017;2:54-5

How to cite this URL:
Zil-E-Ali A, Riaz A. Surgical safety checklist: Outcomes and policing mechanics. Transl Surg [serial online] 2017 [cited 2021 Dec 6];2:54-5. Available from: http://www.translsurg.com/text.asp?2017/2/2/54/208865

Surgical interventions require diligence and a commitment of not only the surgeon but also the operating room staff. The particular attention of the second surgeon, whether it be a resident physician or an attending, calculations of the anesthesiologist, quick responsiveness of the scrub nurse, a well-trained surgical tech team, and the role of operating room manager, all have to be coherent with the lead surgeon. It has been proven that the time in surgery and intraoperative complications can greatly be reduced by a skillful team. However, even with skills, there is not any procedure that promises an outcome free from complications, although the possibility of having serious problems can be reduced.

To affirm the reduction in complications and enhance the communication and efficacy of a lifesaving team, the WHO surgical safety checklist was introduced in 2007. Since then, this has reshaped the safety measures of surgical interventions and also has significantly decreased morbidity and mortality. Before the introduction of this list, surgeons had customized checklists based on the expertise and skills in individual private practices. This led to a lack of ineffective communication among the surgeons and the assisting staff. Some evidence suggests that the theoretical step-by-step approach had actually been employed in the surgery literature for decades. The formulation of this safety checklist was to ensure that everything is managed and delivered in a standard protocol.

Gawande mentioned in his TED talk that as a Harvard surgeon, it was originally felt to be not important to invest time in checklists. However, his team learned of the effectiveness of checklists in other industries and asked the Boeing Aircraft makers to tell them about implementation of such checklists in their own experience. The results of implementing such checklists in surgery were subsequently documented and the death rate was reduced to 35%–47% in hospitals where the checklist was piloted.

This controlled checklist system is helpful in elevating the basic steps that are often forgotten by the team to a more technical level.[1] The checklist has three major sections that efficaciously presents three milestones of communication during a surgery: (a) preoperative or “sign-in” when the anesthesia is induced, (b) just before skin incision or “time-out,” and (c) after skin closure or “sign-out.”[2] These stages have proven successful and most of the international surgery regulatory bodies have already accepted it. The pilot studies conducted in different centers globally brought a significant drop in the post-surgical illness and complications with satisfactory surgical team communications, assuring the efficacy of this important surgical landmark.[3],[4] This led to a global surgical norm and is now become an everyday practice.

The surgical safety checklist is a recent addition to our literature. Compliance with the checklist and its implementation is limited by societal norms, limited resources, lack of training, and weak policing bodies, especially in countries with limited training and high burden of disease. The known language barriers among different nations and an inappropriate implementation of the checklist may foster a wrong approach and failed application of this tool.[5],[6],[7],[8]

Even keeping in mind the limitations of the checklist, de Vries et al.[9] argued over the timing of the checklist and highlighted that half of the standard surgical deviations are before or after the surgery. This argument is relevant in suggesting that omissions and other associated events should be corrected and documented in an earlier stage rather than just before the incision. Instead of a surgical safety checklist, we need to be more particular about the entirety of the surgical pathway from the time patient enters to the time patient is discharged. This is a very appropriate approach and requires standardized protocols that encourage it.

Even after reviewing all the advantages of implementing this checklist and its shortcomings, we recommend that this checklist is something that has to be practiced for the patient's health. However, the question is, “Who is the watchdog in the process?” The answer to it is not available in the academic literature. Who is policing this important checklist? Is the checklist solely dependent on oral briefing? and Are the items on the checklist ticked off randomly? These are some questions that rise if the tool is critically evaluated and must be answered for its efficacy and trusted stature in surgical science. The assurance of this tool and the shortcomings faced in the process of completing it need to be addressed or we would expect things that actually could be counterproductive. The surgical services' directors should devise ways of digitalizing similar tools that are available next to operating table and accessible to the surgeon and the whole team. It is also suggested that every component of this checklist should be checked by the surgeon and counterchecked by the available staff, keeping up with operating environment. This could be done by dictating during the surgery.

Additional effort needs to be expended in finding glitches and then finding possible solutions. Public health experts and surgical leadership have to work together to answer the “if's” and “but's” of it. Overall, this is a satisfactory tool that has saved thousands of lives since its practice. More research will be required to insure that future efforts will be adequate according to the changing surgical demands and newer advances. More efficient protocols are required for its implementation and improvement in this very useful tool.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

World Alliance for Patient Safety. WHO Surgical Safety Checklist and Implementation Manual. Available from: http://www.who.int/patientsafety/safesurgery/ss_checklist/en/. [Last accessed on 2017 Jan 15].  Back to cited text no. 1
Fudickar A, Hörle K, Wiltfang J, Bein B. The effect of the WHO Surgical Safety Checklist on complication rate and communication. Dtsch Arztebl Int 2012;109(42):695-701.  Back to cited text no. 2
Haynes AB, Weiser TG, Berry WR, Lipsitz SR, Breizat AH, Dellinger EP, Herbosa T, Joseph S, Kibatala PL, Lapitan MC, Merry AF, Moorthy K, Reznick RK, Taylor B, Gawande AA. A surgical safety checklist to reduce morbidity and mortality in a global population. N Engl J Med 2009;360(5):491-9.  Back to cited text no. 3
Takala RS, Pauniaho SL, Kotkansalo A, Helmiö P, Blomgren K, Helminen M, Kinnunen M, Takala A, Aaltonen R, Katila AJ, Peltomaa K, Ikonen TS. A pilot study of the implementation of WHO surgical checklist in Finland: Improvements in activities and communication. Acta Anaesthesiol Scand 2011;55(10):1206-14.  Back to cited text no. 4
Vivekanantham S, Ravindran RP, Shanmugarajah K, Maruthappu M, Shalhoub J. Surgical safety checklists in developing countries. Int J Surg 2014;12(5):2-6.  Back to cited text no. 5
Epiu I, Tindimwebwa JV, Mijumbi C, Ndarugirire F, Twagirumugabe T, Lugazia ER, Dubowitz G, Chokwe TM. Working towards safer surgery in Africa; a survey of utilization of the WHO safe surgical checklist at the main referral hospitals in East Africa. BMC Anesthesiol 2016;16(1):60.  Back to cited text no. 6
Nørgaard A, Johnsen R, Marhaug G. How frequently is the WHO Surgical Safety Checklist used? Tidsskr Nor Laegeforen 2016;136(9):815-20.  Back to cited text no. 7
Mahajan RP. The WHO surgical checklist. Best Pract Res Clin Anaesthesiol 2011;25(2):161-8.  Back to cited text no. 8
de Vries EN, Boermeester MA, Gouma DJ. WHO's checklist for surgery: Don't confine it to the operating room. Lancet 2008;372(9644):1148-9.  Back to cited text no. 9


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