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Using the Surgical Safety Checklist to Save Lives

The Alliance for Patient Safety estimates there are 7 million disabling surgical complications and 1 million surgical-related deaths worldwide each year. They identify three primary problems with surgical safety:

  • It is unrecognized as a public health issue.
  • There is a lack of data on surgery and outcomes (especially in developing countries).
  • There is a failure to use existing safety know-how.

Safe Surgery Saves Lives

In an attempt to improve surgical safety, they launched the Safe Surgery Saves Lives campaign. The centerpiece of this program is a checklist known as the Surgical Safety Checklist (WHO World Alliance for Patient Safety, 2009). In order to develop the WHO Surgical Safety Checklist, the authors used the aviation industry checklist framework because of their more than half century of experience in developing and using checklists to improve safety.

All in all, the checklist has proven to be a great success. Eight hospitals from both developed and developing countries participated in a study, and the checklist was shown to improve adherence to standards of care by 65% and reduce surgical-related mortality by half (Weiser et al., 2010). The checklist has three sections: before induction of anesthesia, before skin incision, and before the patient leaves the operating room (WHO Alliance for Patient Safety, 2008).

Advantages of Using the Checklist

  • It can be customized to the local setting.
  • It is strongly evidence-based.
  • It has been evaluated in both developed and developing countries with similar results.
  • It promotes adherence to known best practices.
  • It does not require significant resources to implement.

(WHO World Alliance for Patient Safety, 2009).

WHO Surgical Safety Checklist

The WHO Surgical Safety Checklist is considered highly recommended for short-term surgical projects. In fact, it is best considered a minimum standard of care. The checklist shown here is for illustration and reference purposes only. It is recommended that each surgical team go to the WHO webpage for surgical safety, download the PDF version, and make enough copies to have one for each surgical case. It is also recommended that a copy of the checklist be attached to the permanent patient record.

Of the 234 million people who undergo surgery each year, approximately one million of these individuals die from surgical complications. The WHO estimates that expanded use of the checklist could prevent more than half of these deaths (WHO World Alliance for Patient Safety, 2009).

The following is an overview of each section of the Surgical Safety Checklist. What appears here is only a brief summary of the steps to using the WHO Surgical Safety Checklist. It is recommended that readers download a copy of the WHO Surgical Safety Implementation Guide. A complete list of safe surgery tools, the checklist, an implementation manual, and resources can be found at

A video demonstration on the use of the WHO Surgical Safety Checklist can be found at

phase prior to the induction of anesthesia

At sign-in, the person coordinating the checklist will verbally review with the patient (when possible):

1) Their identity

2) That the procedure and site are correct and that consent for surgery has been given

3) The coordinator will visually confirm that the operative site has been marked and that a pulse oximeter is on the patient and functioning.

4) The checklist coordinator will also verbally review with the anesthesia professional the patient’s risk of blood loss, airway difficulty, and allergic reaction and whether a full anesthesia safety check has been completed.

5) Ideally, the surgeon will be present for sign-in, as the surgeon may have a clearer idea of anticipated blood loss, allergies, or other complicating patient factors.

Timeout before skin incision

The timeout requires that all team members introduce themselves and state their role. The team can simply confirm that everyone in the room is known to each other if more than one case is being done by the same team.

Prior to the skin incision, the team must pause and confirm aloud that they are performing the correct operation, on the correct patient, and on the correct site.

They must then review aloud with one another the critical elements of plans for the operation using the checklist questions for guidance.

It must also be confirmed that prophylactic antibiotics have been given within the previous 60 minutes and that imaging is displayed, when appropriate.


Once sign-out is initiated, the nurse verbally confirms with all team members:

  • The name of the procedure recorded
  • That the instrument, needle, and sponge counts are correct and reconciled prior to closure
  • If counts are not reconciled, the team is alerted to search for missing items in, on, or around the field. X-rays are requested if counts still do not reconcile.

(WHO Alliance for Patient Safety, 2008)


Weiser, T. G., Haynes, A. B., Lashoher, A., Dzeikan, G., Boorman, D. J., Berry, W. R. (2010). Perspectives in quality: Designing the WHO surgical safety checklist. International Journal of Quality in Healthcare, 365–70.
WHO World Alliance for Patient Safety. (2008). Summary of the evidence on patient safety. Geneva: World Health Organization.
WHO World Alliance for Patient Safety. (2009). Conceptual framework for the international classification for patient safety. Geneva: World Health Organization.

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