The World Health Organization Surgical Safety Checklist

The World Health Organization (WHO) Surgical Safety Checklist was developed after extensive multinational and multidisciplinary consultation that included surgeons, anaesthetists and operating room nursing staff. It was produced by the WHO’s Safe Surgery Saves Lives programme in 2008. On 19 August 2009, the Checklist was jointly launched in Canberra by the Australian Minister of Health, the Royal Australasian College of Surgeons (RACS), the Australian and New Zealand College of Anaesthetists (ANZCA), the Royal Australian and New Zealand Colleges of Ophthalmologists (RANZCO) and Obstetrics and Gynaecology (RANZCOG), the Australian College of Operating Room Nurses (ACORN) and the Perioperative Nurses College of the New Zealand Nurses Organization. A week later it was launched in New Zealand. Modifications and additions were invited to suit local hospital practice, as per the original WHO checklist in the hope of encouraging local ownership and engagement. Throughout Australia and New Zealand the checklist has become a standard protocol, albeit with various locally derived refinements. The efficacy of the Surgical Safety Checklist has an extensive evidence base. It was intended to prevent the should-be-never event of wrong patient and wrong site surgery, ensures intended prophylactic antibiotic and deep vein thrombosis prophylaxis are given, documents agreement that there has been accurate recording of correct swab/instrument counts (another never event) and which pathological specimens are to be dispatched. Initial multicentre studies led by local champions of the checklist, including Auckland City Hospital, yielded good early evidence that its introduction was associated with reduced mortality and morbidity including surgical site infections. Unfortunately later meta-analyses have been hampered by the heterogeneity of surgical safety checklist studies, and a 25-paper systematic review by Australian and Swedish authors found total complication rates were reduced in five of six studies (83%) conducted in developing nations but only in 5 of 14 (36%) of developed countries. Despite the early promise, the 14 included developed nation studies did not even show a combined overall reduction in mortality. The WHO Checklist has three components – sign in, time out and sign out – with some 19 checkpoints though the number of these vary with local adaptation. Audits of compliance have produced varied and often disappointing results reporting that team members were often absent or disengaged and checks were incompletely performed. An Australian qualitative study published in this journal from the Gold Coast described an array of behaviours and excuses that compromised full participation in the Surgical Safety Checklist process, including workload, time-constraints and staff availability. The quantitative study in 11 Australian hospitals published in this issue of the journal confirms an inconsistent compliance with the checklist process in Australia. Despite mandating completion of the checklist, accuracy rates have remained disappointingly poor. Such poor rates suggest a problem with the checklist or allude to issues with operating room communication, collaboration and culture. Indeed there is a need for cultural change in the surgical workplace, something that has been recognised in the RACS Building Respect Improving Patient Safety Action Plan and Operate with Respect Campaign. Surgeons have an opportunity to demonstrate leadership in the operating theatres, by showing engagement and being good role models for participation. The Surgical Safety Checklist is an opportunity for team building. It can provide a moment where everyone can be briefed on issues relating to the case in hand and what to expect, and who is doing what as the procedure progresses. Everyone present needs to understand and relish their role, but should also feel free to speak up for the patient’s safety. Opportunities for followership and leadership change during the various stages of a procedure and the checklist personifies this in that the anaesthetist leads the sign in, the surgeon often leads the time out, while nursing staff usually are responsible for the sign out. The checklist should not be used as a compliance audit of each separate component. It was never intended to be used as an audit but intended to improve compliance with safe surgical and anaesthesia processes. Some of the failures to include every element of the checklist are caused by the misconception that each item to be mentioned should be separately ticked and be audited. This is impracticable. Replacing the paper checklist with large wall charts that can be read by all team members restores the spirit of what was intended when it was introduced as has occurred in New Zealand and many Australian hospitals. The wall chart checklists should encourage engagement and participation, communication and teamwork. The checklist may reduce mortality and morbidity even where compliance is poor. However, that offers no excuse for poor compliance, because compliance offers the surgical team opportunities to make the workplace a more respectful and happier environment that champions professionalism and appropriate behaviours. There is also no place for cynicism, or undermining humour – the checklist is something our patients expect us to engage in and were they awake they would be horrified if they found key team members were not pulling together for the best possible outcome.