Checklists have improved surgical outcomes in clinical trials and are widely recommended, but a recent observational study showed no change in surgical outcomes following checklist adoption. This study sought to improve adherence to surgical checklists at a single institution. Trained observers assessed checklist performance over three 1-year periods during which various interventions were implemented. The authors report only 30% adherence to the WHO surgical checklist 1 year after adoption. Developing clinician leadership, teamwork training, and stakeholder engagement led to a significant increase in checklist adherence 2 years following implementation. This work underscores the resources and effort needed for successfully implementing safety checklists. In a past AHRQ WebM&M interview, Peter Pronovost discussed utilizing checklists as a tool to improve patient safety.