Issue 22 / 23 June 2014

A LOT has been written about the role of checklists in improving the safety of surgery.

The WHO, through its Safe Surgery Saves Lives initiative, led the development of the WHO Surgical Safety Checklist (SSC).

In 2007–2008, the SSC was piloted in eight hospitals in both high- and low-income countries, with the results published in the New England Journal of Medicine in 2009.

I’m simplifying, but in essence the study showed that after the implementation of the SSC there was a reduction in the surgical death and complication rate by more than one-third, with a halving of the surgical death rate alone.

Striking results indeed.

The WHO estimates about 234 million people are operated on each year and, by current estimates just over a million of these people — many in low-income countries — will die from complications. Extrapolating from the NEJM study, 500 000 people who would otherwise die could be saved if the surgical safety checklist was used as intended.

Half a million people every year.

So why are there opponents to the widespread and mandated use of the SSC? Some see the compulsory use of checklists as “cookbook medicine” while others see it as an unnecessary additional workload — another form to tick, in an already paperwork-heavy workplace.

Others see the surgical checklist as just another example of bureaucrats getting in the way of the main game of getting surgery done.

To an extent, I agree with some of these arguments. The burden of mandatory forms and signatures required for even the simplest of cases can be frustrating, and can make it difficult to separate the signal from the noise.

Still, others see the use of the checklist as simply ineffective at improving outcomes. A recent study, also published in the NEJM, detailed the experience of investigators in Ontario, Canada after the implementation of the SSC.

What did they determine? No difference.

Their already impressively low rates of postoperative complications and death were not further improved with the surgical safety checklist — at least not in a largely noticeable or significant way. They demonstrated the principle of diminishing returns and showed that the better you are to begin with, the harder it is to improve.

But what about the diploma-trained anaesthesia technical officer in rural Uganda, who is prompted to use a pulse oximeter or notices the oxygen cylinder is empty during their similarly prompted machine check?

Does it make a difference then? Should they read the NEJM paper and similarly dismiss the checklist? I think not.

Even in Ontario, for the one, or two, or maybe 10 people who avoided surgical site infection because their anaesthetist was prompted by the list to give antibiotics prior to skin incision — it made a difference to them, too.

Perhaps the checklist made a difference also for the junior nurse, who now knows the names of the people he works with and might feel more able to speak up if he doesn’t understand the plan or sees something dangerous about to happen.

Don’t throw the baby out with the bathwater. Checklists by themselves are just another piece of paper, but it’s not about the piece of paper.

It’s about the culture of a surgical team and its ability to work effectively all of the time and not just most of it. It’s about getting the simple things — like antibiotics and thromboprophylaxis and oxygen and each others’ names — right, every time.

Aviators are surprised that checklists like they use are not used in medicine. Early on in their history, they had their fair share of “oops-forgot-the-landing-gear” moments, and they have used checklists to adapt their culture to the increasingly complex demands of flying.

Until we come up with a better idea, checklists seem like a pretty good way for us to adapt our culture to the growing complexity of surgery.


Dr Simon Hendel is an anaesthetist and an intern at the Global Surgical Consortium.


Should the WHO surgical safety checklist be mandatory in Australia?
  • Yes (78%, 32 Votes)
  • No - checks already in place (12%, 5 Votes)
  • No - it's an individual choice (10%, 4 Votes)

Total Voters: 41

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4 thoughts on “Simon Hendel: The big tick

  1. Randal Williams says:

    The surgical safety checklist is a valuable tool in the public hospital system where there are regular multiple staff changes , and often not a continuous and consistent surgical team, as mostly you see in private practice. In some situations in public practice staff may be totally unfamiliar with the procedure or the team. The surgeon performing the procedure may be a registrar who has never seen the patient before. hence the potential for mistakes and omissions, which we don’t see so much in private where the consultant does the operation and is familiar with the patient, has his own notes etc. The surgical safety checklist is therefore most valuable in public hospitals, large hospitals wirth regular staff rotations etc but is best universally applied so it becomes an accepted routine. It can be modified in private eg it may not be necessaryy for staff to introduce themselves.

  2. Glen smith says:

    Checklist should be a part of a comprehnsive package to improve patient safety and outcomes. Yes aviation uses checklists, they also use a myriad of other tools to reduce error and poor outcomes. In some cases the use of checklist has resulted in an incident occcuring.

    One of those tools is crew resource management, which is used to assist communication between the various stakeholders in a cockpit and beyond. The raionale is that all of the players involved in the aircraft performance see aspects  that can contribute to better outcomes. As it was found that the most experienced pilots could cause poor outcomes as they ignored input from the other members of the team. Lke this holds true in medicine also my belief is that this tool has been adapted for us in medicine

    Clearly medicine needs a suite of tools based on humand factors and ergonomc approaches that address human behavior and the environment as much practiable to ensure patient safety and outcomes.


  3. Robert Tucker says:

    Surgical ‘checklists’ have been around far-longer than indicated in this article ! As  an Australian udertaking surgical training in the UK from late 1970’s it was one of the “registrars-responsibilities”,wihout-exception for the trainee to check the ‘paient-in’ and verify ALL patient details!!

    So,why ? are there still difficulties……………….


  4. Randal Williams says:

    One further comment;

       the operating surgeon,  under consultant supervision if appropriate, must take ultimate responsibility for correct patient, correct operation, correct side,  also for antibiotic / DVT prophylaxis, and alerting the anaesthetist to potential or actual problems.   Noise levels in theatre must also be kept under control so that effective communications can occur intra-operatively. Sometimes equipment alarms are not heard because there is too much extraneous noise or too many devices “beeping”

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