The remarkable initial success of the World Health Organization surgical safety checklist led to the United Kingdom's National Health Service mandating its use in 2009. Subsequent studies of the checklist, however, have failed to demonstrate improvements in perioperative complication rates. This study analyzed the relationship between checklist implementation and complication rates at five hospitals in the UK. The investigators found that the checklist was effective only when it was fully completed—the odds of a postoperative complication were reduced by more than 40% if the full checklist was completed, but this was done in only 62% of cases. Moreover, even complete checklist usage did not seem to prevent complications in low-risk patients. The results of this and other studies clearly demonstrate that a checklist is a complex intervention that requires rigorous implementation and monitoring in order to improve safety.

This direct observation study used a standardized protocol to assess the implementation of the safe surgery checklist and found wide variation in actual use of the tool. Challenges with implementation are thought to explain varying efficacy of checklists in clinical practice, in contrast to dramatic reductions in surgical mortality and complications in clinical trials.

The initial introduction of the World Health Organization surgical safety checklist was associated with impressive improvements in patient safety. However, more recently a study of the government-supported implementation of the checklist in Canada showed no beneficial effect. This study examined the mandated introduction of the surgical safety checklist in hospitals across England and discovered large variation in how the checklist was initially implemented. The most common barrier encountered was resistance from senior clinicians. The authors provide generalizable recommendations to guide the future implementation of improvement efforts. A recent PSNet interview with Dr. Lucian Leape discussed his perspective on the effect and implementation of checklists for patient safety.

The World Health Organization's surgical safety checklist has been associated with reductions in postoperative complications in both planned and urgent surgical procedures. Despite this, real-world implementation of the checklist has proven to be difficult. In this study conducted in the United Kingdom, postoperative patients strongly supported use of the checklist during procedures, feeling that it would improve safety and teamwork during their procedure. The authors argue that patients' desire for the checklist use could be utilized as a means of overcoming cultural barriers to checklist implementation. Interestingly, despite their support for the checklist, most patients in the study did not feel they had a role to play in improving patient safety and did not wish to be more involved in safety efforts.

This systematic review found that safety checklists in the operating room measurably augment teamwork and communication, which may explain how they improve patient outcomes.

Surgical equipment failures have been implicated as a significant contributor to errors and delays in the operating room. This systematic review found that equipment problems account for a large proportion of operating room errors, although the exact number could not be determined due to differences in study methodology. As the majority of equipment problems were due to potentially preventable issues (such as equipment being unavailable or improperly configured), the authors argue that equipment checks should be incorporated into surgical safety checklists. Preoperative time outs are also an effective means of prospectively identifying potential equipment issues. A postoperative complication caused in part by equipment unavailability during surgery is discussed in an AHRQ WebM&M commentary.

This observational study at a large teaching hospital found that process failures in postoperative care were common, and often preventable, causes of patient harm.

This qualitative study found considerable evidence for communication failures between clinicians at each stage of the surgical pathway. A surgical checklist has been shown to improve patient safety, in part by using structured handoffs to avoid communication issues.

A brief safety skills course that included training on error analysis and specific surgical safety methods resulted in sustained improvement in surgeons' knowledge and attitudes toward patient safety.

One key characteristic of high reliability organizations is maintaining sensitivity to operations—understanding of and attentiveness to issues faced by frontline workers. While maintaining a culture of safety is an important facet of attending to frontline workers' concerns, a more mundane but equally important aspect is ensuring that workers can reliably complete their tasks. This survey of seven National Health Service hospitals found poor task reliability across several clinical processes. For example, essential operating room equipment was unavailable in up to 37% of cases at one hospital, and at another, clinical information was missing for 27% of patients being seen in an outpatient clinic. Missing equipment or information leads to interruptions in performing tasks, which have been linked to increased rates of adverse events. Some hospitals did achieve higher reliability, and the authors cite standardization of processes as one factor leading to improved reliability.

This commentary discusses the use of communication improvement tools as part of a larger systems strategy to prevent errors in surgery.

Communication failures are common in surgical care. This study used a novel assessment tool to evaluate information handoff during the preoperative, intraoperative, and postoperative periods, and found significant problems in each phase.

This systematic review of 38 published studies identified communication failures in all phases of surgical care, including intraoperatively and during postoperative care. Such breakdowns in information transfer, particularly during handoffs, have been linked to adverse events in prior studies. A number of interventions have been proposed to address this issue, including standardized checklists—which were remarkably successful at reducing postoperative complications in a classic study—and incorporation of handoff techniques from other industries. An AHRQ WebM&M commentary discusses the disastrous consequences of an intraoperative communication breakdown.

This study used failure mode and effect analysis to identify safety risks in perioperative care due to poor communication.

This qualitative study interviewed 18 providers and found that postoperative handovers are informal, unstructured, and fraught with inconsistent and incomplete information transfer. These data were used to develop and validate a formal handover protocol. Prior studies have used insights from Formula One auto racing to inform improvement strategies for postoperative handoffs, and the World Health Organization's Surgical Safety Checklist explicitly emphasizes structured handoffs at the time of patient transfer from the operating room to the postoperative area.

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.

This commentary reflects on data from the United Kingdom's National Health Service to underscore the current inadequacy of methods to measure safety. Similar to a past commentary from the United States, the authors call for more systematic data collection strategies that will better monitor and track progress in patient safety.

The investigators developed a bleeding crisis simulation and found differences in the technical and team skills of junior and senior trainees.

The authors describe their use of simulation as a tool to develop skills in surgical trainees.