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Transforming Evidence: WHO Surgical Safety Checklist

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Keywords: WHO surgical checklist, surgical operation, operations, checklist, surgeon


Surgery and surgical processes are becoming inevitable in the treatment process for particular conditions and diseases. The risks associated with surgeries may start from as early as from the anaesthesia stage – and the more complex the surgery, the greater the risks (American Cancer Society, 2013). In 2008, WHO launched a patient safety challenge titled ‘Safe Surgery Saves Lives’ and the safety checklist was part of the outcome (NHS, 2009). In 2009, NPSA ordered all hospitals in England and Wales to adopt and implement the checklist by February 2010. In the directives, NPSA ordered all hospitals to: ensure clinical leads are identified to implement the surgical safety checklist within the hospitals, ensure the checklist is complete for every patient undergoing surgery, and ensure the use of the checklist is entered in the electronic records of the hospital by a member of the team. In the United Kingdom, many patients undergo surgery every year, and the implementation of the checklist is an important strategy for saving lives that are already at risk (BBC, 2009). As of 2012, there were 4000 hospitals in 122 countries that were registered users of the WHO surgical safety checklist (Walker et al., 2012).

Literature Search Strategy

A comprehensive literature search strategy was employed to gather all evidence regarding the WHO surgical checklist. The sources of information was not narrowed to one specific medium, rather all available sources were used –including the Internet. In the search for credible publications to provide evidence, the following questions were developed to provide insight:

What are the obstacles to implementation?

Are there alternatives to the WHO surgical checklists?

How efficient are surgical checklists in improving safety in theatres?

To ensure that sources obtained are up-to-date, only literature published from 2008 onwards was used. To ascertain the success of implementation and efficiency of the surgical checklist in hospital set ups, various studies and surveys on the checklist –conducted in hospitals -- were used. The CINHAL database provided important information regarding the checklist. To get accurate information on the checklist, specific keywords --such as WHO checklist, safe surgery, and Implementation of surgical checklist -- were used. Also, various nursing books available at Google books offered insight into the whole process. The contributions of peer reviewed nursing journals, as well as scholarly nursing articles available at Google Scholar were not left out. In addition, various medical and nursing websites were used to source information. In the search for sources of information, relevance of the information and credibility of the source was considered.

Literature Review

The WHO surgical safety checklist is divided into three phases of the surgical procedure. A review of the checklist at the WHO (2014) website provides details for each phase. For instance, at the initial stage of ‘checking in’, the list requires information on patient’s allergies, aspiration risks, risks of blood loss, and safety check for anaesthesia. In addition, the section ensures that patient has confirmed the site, identity, and procedure, and consent for the procedure to take off. At the ‘time out phase’, the entire list requires the nurse, surgeon, and anaesthesia professional to verbally confirm the patient, site, and procedure. Also, the team members must introduce themselves by name and role. In addition, the team members conduct different reviews on the patient – depending on their respective roles. The last phase – sign out – requires .the nurses to verbally confirm with the team on: name of the procedure; how the specimen is labelled; confirm the count of needles, sponge, and instrument is correct; and any equipment problems to be addressed. The team members must review the key concerns for the recovery of the patient. Modifications of the checklist to fit local procedure are allowed (WHO, 2014).

At the initial drafting of the WHO safety checklist, there was little experience, if any, in the development of checklists. The authors of the WHO surgical safety list heavily relied on the Aviation industry to create an essential safety tool for nurses. The Aviation industry has approximately 75 years of experience in developing checklists. The methodologies applied were heavily borrowed from the airline industry (Weiser et al., 2010). Robotic surgeries have increased risks and challenges to care providers, and surgical checklists are essential to reduce peri-operative complications (Song, Goutham, Jonathan, and Sam, 2013).

The WHO surgical safety checklist has been instrumental in improving safety and saving lives of patients under surgical operations. Proper implementation of the checklist, based on the implementation manual provided, is guaranteed to improve safety in the theatres. ECAB (2012) concurs with sentiments, admitting that the checklist has been adopted in many hospitals across the world. Indeed, there have been marked reductions in the postoperative complications – after implementation of surgical checklist are reported (Annals of Surgery, 2012). There are reports, however, of incomplete compliance with the checklists. A cohort study conducted on 25,513 adult patients going through non-day case surgery established that crude mortality reduced from 3.13 percent to 2.85 percent –after implementation of the checklist. In the study, patient records and hospital administrative data was used to obtain the necessary data for the research (Annals of Surgery, 2012). In the book titled “Contentious Issues in Surgical Gastroenterology”, the various benefits accrued form the checklists are elucidated (ECAB, 2012).

At its initial introduction into the system, the WHO safety checklist was subjected to trials in various hospitals across the globe. These measures were necessary to ascertain the efficiency of the checklist before full implementation in the theatres. A UK pilot experience conducted by the Imperial College London established the effectiveness of the checklist (Vats et al., 2009). In the pilot experiment, two operating theatres were used, representing the bulk of surgeries conducted in the NHS – gastrointestinal and gynaecological procedures, and trauma and orthopaedic surgery. In this study, the checklist process was led by nurses, and data on the current practice was collected. The research found the nurses and anaesthetists were supportive of the procedure, but several surgeons were not enthusiastic about the procedure (Vats et al., 2009). During the time of drafting the first edition of the WHO safety checklist, there was little experience, if any, in the development of checklists. The authors of the WHO surgical safety list heavily relied on the Aviation industry to create an essential safety tool for nurses. (Weiser et al., 2010).The Aviation industry has approximately 75 years of experience in developing checklists. The methodologies applied were heavily borrowed from the airline industry.


The implementation of the WHO surgical checklist is guided by standard manuals provided by WHO(NPSA,2013). In view of the necessity to properly implement the checklist, an analysis of the benefits accrued is important. The benefits notwithstanding, a further analysis of the shortcomings will provide insight into possible modifications, changes, or alternatives for the WHO surgical checklist.

Benefits and Obstacles

The WHO surgical safety checklist has become a useful tool in reducing surgical morbidity and mortality (ECAB, 2012). For instance, researchers in Netherlands have established that the WHO safety checklist have reduced mortality by 50 percent, and morbidity by a third (ECAB, 2012). In addition, the checklist does not require any financial investment, making it accessible to all hospitals. The WHO checklist is just a one page document, and requires less than a minute to complete it (BBC, 2009). When the WHO surgical safety checklist was released in 2008, it was met by scepticism from various medical practitioners. Its effectiveness and reliability, however, has led to embracing and adoption of the checklist in many hospitals. A study conducted on the treatment of trauma and orthopaedic patients shows a significant improvement on the safety after implementation of the checklist. Also, the study –conducted by International Orthopaedics – found that the use of checklists improved team communication (Sewell, et al, 2011).

Universal acceptance of the WHO surgical safety list is still low, and its simplicity creates a negative perception among practitioners. For some nurses, such a basic tool cannot guide safety measures in the theatre effectively (ECAB, 2012). There was a growing perception that the WHO safety checklist may not be effective among low-income set up and in third world countries. A study published in the British Medical Journal, however, refutes this claim, and proves that the checklist is effective in any set up. The research was based on operations in one African University hospital and two UK University hospitals. The outcomes indicated similar challenges, similar benefits, and similar experiences in both set ups (Aveling, McCulloch,and Dixon-Woods, 2013). The associated benefits of the WHO surgical safety checklist and its ability to save lives make it a mandatory tool in all hospitals.

Implementation Using Lewin’s Change Theory

In response to the shortcomings and obstacles to the implementation of the WHO surgical checklist, there is need for modifications of the current checklist. Lewin’s change theory provides a perfect model upon which the change can be implemented. Lewin’s theory defines human behaviour as a dynamic balance of forces working in opposing directions. According to this theory, the changes occur in three phases –unfreeze, change, and freeze -- propelled by various forces. (Nursing Theories, 2011).

The first phase, unfreeze, starts with the realisation that there is need for change – based on the shortcomings of the checklist. There is need, therefore, to create awareness among nursing professionals and instigate the necessary motivation for the change. Also, unfreeze stage entails the reduction of forces that advocate for the status quo. For instance, some professionals may argue that simplicity of the checklist makes it easier to implement, and change is not necessary. Such challenges can be dealt with by emphasising the severity of the shortcomings of the checklist. For example, the checklists are not a perfect fit for all hospitals, making it impossible to effectively implement (Change Management Consultant, 2014). A forced field analysis on the WHO surgical checklist would be effective in reducing the restraining forces, and subsequently determine if the proposed change can get support from all stake holders. Also, driving forces should be increased. (NHS, 2013).

The unfreeze phase sets the pace for the overall change process to begin. The change stage is associated with resistance by advocates of the status quo. In addition, the uncertainty of the benefits of the change process may prevent individuals from supporting the initiative. The transition, however, will be propelled on the strength of the driving forces, and weaknesses of the restraining forces (NHS, 2013). At this stage, new values, behaviours and attitude towards the WHO checklist is developed. Specific focus on development of this attributes is on the nurses. To avoid confusion as the checklist is transformed from one model to a new one, efficient communication among all stake holders is crucial. Once the benefits of the changes to the checklist start to be realised, the transition process will be embraced by all. Despite these achievements, resistance from negative forces must always be anticipated (Change Management Consultant, 2014).

The last stage –freeze – marks the acceptance of the change as a new norm in theatres. The new surgical checklist is universally accepted, and benefits accrued from the changes are appreciated. The freezing stage eliminates confusion among people who are not sure about the whole change process. Kurt Lewin’s change theory assumes that nurses may revert to old ways of doing things, unless changes are reinforced. As an important stage of continuity, freezing creates certainty on the current model before another change process can start through unfreezing. With passing of time and development of shortcomings, a similar cycle is repeated to achieve desired results. (Change Management Consultant, 2014).

Strengths and Weaknesses of Lewin’s Change Model

Lewin’s change theory is applicable in all situations, whether the changes are strategic, incremental, reactive, or anticipatory. This makes the model a perfect fit for changes in a hospital set up. The simplicity of the model further validates its choice as the basic guideline for changes in the theatre. In addition, the model is divided into few clearly defined stages, and evaluation at every stage predetermines advancement to the next phase. Some challenges, however, are experienced in the application of Lewin’s model. For instance, the nurses may experience change shock during the refreezing phase (Change Management Consultant, 2014).


For effective implementation of the WHO surgical safety checklist, there should be competent leadership in the application of the checklists in theatres. Lack of appropriate leadership, therefore, may lead to errors and miscommunications in the theatre. Implementation of the checklist starts from the briefing session, and an appointed leader should offer the directions. The debriefing section is one of the most important processes in implementation of the checklist, and also the hardest to do (SMA, 2010). Each team member in the theatre has defined roles, and the responsibilities assigned to each determine the ultimate leader. Divisional managers and nurses should ensure compliance of the safety checklist within their designated areas. The theatre manager has the obligation of ensuring the implementation of the checklist on a day-to-day basis, as well as maintains the safety standards within the hospital. In addition, all individual staff within the set up must work within their sphere of competency and remain vigilant for discrepancies and report as necessary. The senior operating surgeon retains the overall accountability to ensure that the checklist is completely robust (Royal Cornwall Hospitals, 2012).


The attention levels among team members in the theatres are dependent on several factors. For instance, personal life experiences – outside the hospitals – may affect the levels of concentration among the practitioners. This is a major challenge for the proper implementation of the WHO surgical safety checklist. Also, lack of attention is a barrier for effective communication between the nurses and surgeons. Proper attention is required to properly govern surgical count in the theatre. There is need, therefore, to strike a balance between personal judgments and organizational policies to achieve desired results – including proper attention (Manias and Polglase, 2006).


Before surgical procedures, patients are subjected to anaesthesia. This procedure makes patients not feel pain during the operation. This medication may make the patient unconscious – although not in all cases (patient.co.uk, 2012). When the patient is asleep, chances are that the surgeons and nurses may discuss the patient. The medical professional ethical standards do not encourage discussion of patients, if the content of the discussion is not in the best interest of the patients. To do so, is an infringement of the privacy of the patient, and a violation of professional standards. During operations, however, it may be necessary for such discussions to take place – in an attempt to strategize appropriate steps forward according to the patient’s status (Kavarana, 2012).


Various studies have proved beyond doubt that surgical safety checklist reduce mortality rates in hospitals. Also, the checklists have reduced morbidity rates. With the risky nature of operations and complexities of the diseases under treatment, these checklists have increasingly become mandatory for every surgical operation. The formulation of the WHO surgical safety checklist in 2008 marked the beginning of improvement in the safety welfare of patients under surgical operations. The directive by NPSA to all hospital to comply with the WHO safety checklist was the right step towards the achievement of better safety measures for patients. Whereas the implementation faced challenges at the initial level, the WHO checklist has become popular with time. Its simplicity has endeared it to the users, making the implementation process easier. In addition, the WHO clause on the modification of the checklist allows nurses and surgeons to modify the checklist to suit particular conditions. The checklist acts as a reminder to both nurses and surgeons of the necessary safety measures required in the theatre.


he weaknesses associated with the WHO surgical safety checklist are minor – compared to its benefits to patients. The essence of any safety checklist in a hospital set up is to reduce mortality rates, and the WHO safety checklist has recorded success in achieving this objective. As such, the strength of the safety checklist still makes it a priority in theatres. Proper education for nurses on the use of the checklist is important. In addition, the WHO provides a manual to guide users in the implementation of the checklist. Effective communication is important during the surgical operations, and there should be emphasis on the importance of team work. Also, attention during surgical procedures can minimize errors which are risky to the patients. For instance, cases of instruments remaining in patients are largely attributed to lack of attention during the operation. The WHO safety checklist ensures such risks are minimized – through the verification of instruments during and after the procedure. Other alternative checklists have proved to be effective in guaranteeing safety measures in the theatre. The blue and AORN surgical safety checklists share significant similarities with the WHO surgical safety checklist. The few shortcomings in the WHO checklist should provide motivation for medical researchers to formulate improved versions of the safety checklist. There is potential for improving the practice and culture of surgical patient safety activity (Karyadinata et al., 2012).

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