The WHO surgical safety checklist has been implemented in healthcare systems around the world. Survey responses from 2,032 surgical team members from high-income countries suggest that most respondents perceive the checklist as enhancing patient safety, but that not all team members are engaging with its use or feel confident in their role in the checklist process.

Checklists are a popular yet controversial strategy for improving the safety of frontline care. The authors in this commentary debate the weaknesses and strengths of checklists through a discussion of the evidence.

This study in the Health Affairs patient safety theme issue examines the implementation of surgical safety checklists. Checklists have been shown to improve patient outcomes in randomized control trials, but implementation studies have not consistently demonstrated similar improvements. In this statewide initiative, implementation of the checklist varied significantly among sites. Factors associated with more successful implementation included greater leadership participation, frontline engagement, and more frequent activities for all involved groups, including surgeons, nurses, technicians, and administrators. Sites that invested more funding and time also saw greater checklist implementation. The authors conclude that hospitals that participated more did better. Past PSNet interviews with Lucian Leape and David Urbach discussed their perspectives on surgical safety checklists.

Physicians who receive more patient complaints about communication and behavior are more likely to face malpractice claims. This study examined whether results from surgeons' 360-degree reviews, in which team members evaluate a range of professional attributes and behaviors, were associated with risk of malpractice claims. Surgeons with worse performance for attentiveness, informing others, and considering others' suggestions had a significantly higher risk for malpractice claims. Surgeons in the highest 10% for the negative behaviors of snapping at or talking down to others also were more likely to have malpractice claims. These results echo prior studies of physician behavior and malpractice risk. The authors suggest that addressing negative behaviors among surgeons could mitigate malpractice risk. A previous WebM&M commentary discussed patient complaints as safety surveillance.

Establishing a robust culture of safety, in which all staff feel free to voice concerns without fear of reprisal and leadership explicitly prioritizes safety, is crucial to safety improvement efforts. The most successful safety improvement programs have all explicitly prioritized enhancing safety culture. This study reports on the baseline results of a program that sought to improve surgical safety at hospitals in South Carolina. Safety culture was assessed among operating room personnel in 31 hospitals using a validated instrument. The investigators found a relatively robust association between better perceived safety culture and lower 30-day postoperative mortality. Studies in other clinical settings have found similar results. The hospitals involved in this study subsequently participated in a program to implement the Surgical Safety Checklist, which resulted in a significant improvement in mortality among participating hospitals compared to nonparticipating hospitals. A recent PSNet interview with Dr. Mary Dixon-Woods discussed the evolving concept of safety culture.

The large surge in opioid use is a serious patient safety problem. This retrospective study revealed that risk of postoperative inpatient opioid overdose increased over time. Patients with a substance abuse history were more likely to experience a postoperative opioid overdose, but hospital characteristics did not predict this complication. This finding suggests that high-risk patient characteristics should be taken into account in prescribing opioids after surgery.

Checklists have been shown to reduce surgical morbidity and mortality in randomized trials, but results of implementation in clinical settings have been mixed. This study reports on a voluntary, statewide collaborative program to implement a surgical safety checklist in South Carolina hospitals. Participating sites undertook a multifaceted process to support checklist implementation and culture change. Cross-institutional educational activities were available to all hospitals in the collaborative. Investigators determined that rates of surgical complications declined significantly in hospitals involved in the collaborative compared with those that did not participate, which had no change in postsurgical mortality over the same time frame. Past PSNet interviews with Lucian Leape and David Urbach discussed their perspectives on surgical safety checklists.

Although checklists have been shown to improve safety and surgical mortality, they can be difficult to implement, which limits their effectiveness in clinical practice. This study examined whether perceptions of teamwork predicted checklist performance. Trained observers used standardized tools to rate the extent of checklist completion and quality of teamwork. They found that checklists were implemented as intended in only 3% of cases. Surgical teams with better surgeon buy-in to checklists, clinical leadership, communication, and overall teamwork completed more checklist components. Clinical factors, including older patient age and longer duration of surgery, were also associated with performing more of the checklist. The authors suggest that teamwork is critical to checklist implementation. A PSNet interview discussed the challenges of implementing checklists in health care.

Surgical checklists have been associated with reduced morbidity and mortality in randomized trials, but real-world implementation has not always resulted in improvement. This pre-post study reports on an initiative to implement surgical checklists in South Carolina hospitals. Investigators surveyed surgical personnel before and after checklist implementation. Compared with the pre-intervention responses, measures of teamwork improved, and 54% of participants reported effective checklist compliance. The study did not report on changes in patient outcomes after checklist introduction, which would substantiate calls for implementing checklists widely. A PSNet interview with Dr. Lucian Leape discussed his perspective on checklists and patient safety.

The World Health Organization's surgical safety checklist has been successfully implemented in multiple clinical settings. This study, conducted in Moldova, found that checklist usage remained high 2 years after initial implementation, with postoperative complication rates continuing to decline over that time period.

This commentary describes how the WHO Patient Safety Surgical Checklist was created using lessons learned from aviation experience in checklist development.

Checklists have proven to be a remarkably powerful patient safety intervention. A vivid demonstration of the power of checklists came in a landmark World Health Organization study of a safe surgery checklist, which achieved significant reductions in mortality and complication rates in a global population. One criticism of checklists is that in urgent situations, pausing to ensure checklist completion could be harmful. However, this subgroup analysis of the original WHO study found that the surgical safety checklist successfully reduced mortality and complications in patients undergoing urgent surgery (defined as operation within 24 hours of assessment). This study also demonstrates the feasibility of implementing standardized safety interventions in hospitals with widely differing resources and patient populations.

Success in patient safety is generally measured in incremental steps rather than giant leaps, but this pioneering study certainly represents the latter. Eight hospitals with widely differing resources and patient populations were required to implement a checklist based on the World Health Organization's Safe Surgery Saves Lives guidelines. The 19-item checklist focused on three key junctures: sign in (before induction of anesthesia), timeout (immediately before skin incision), and sign out (when the patient is ready to leave the operating room). It also included specific measures to improve teamwork and reduce the risk of surgical site infection. Checklist implementation resulted in significant reductions in mortality and inpatient complications. Checklists have already proved to be a powerful intervention in improving patient safety. This study's senior author, Atul Gawande, wrote about the success of checklists in preventing central-line associated bloodstream infections in a 2007 New Yorker article.