WHO safe surgery checklist reduces deaths and complications

21 January 2009

The WHO Safe Surgery ChecklistHospitals 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 Lives' initiative.

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 checklist.

“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 patient).

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.”

Further information

The WHO Safe Surgery Saves Lives initiative:

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