Ambulkar R, Ranganathan P, Salunke K, Savarkar S. The World Health Organization Surgical Safety Checklist: an audit of quality of implementation at a tertiary care high volume cancer institution. J Anaesthesiol Clin Pharmacol. 2018; 34:(3)392-398

Bergs J, Hellings J, Cleemput I Systematic review and meta-analysis of the effect of the World Health Organization surgical safety checklist on postoperative complications. Br J Surg. 2014; 101:(3)150-158

Boillat T, Grantcharov P, Rivas H. Increasing completion rate and benefits of checklists: prospective evaluation of surgical safety checklists with smart glasses. JMIR Mhealth Uhealth. 2019; 7:(4)

Brindle ME, Henrich N, Foster A Implementation of surgical debriefing programs in large health systems: an exploratory qualitative analysis. BMC Health Serv Res. 2018; 18:(1)210-215

Crowe critical appraisal tool (CCAT) user guide. 2013. (accessed 7 November 2022)

Dabholkar Y, Velankar H, Suryanarayan S, Dabholkar TY, Saberwal AA, Verma B. Evaluation and customization of WHO Safety Checklist for patient safety in otorhinolaryngology. Indian J Otolaryngol Head Neck Surg. 2018; 70:(1)149-155

de Vries EN, Prins HA, Crolla RMPH Effect of a comprehensive surgical safety system on patient outcomes. N Engl J Med. 2010; 363:(20)1928-1937

Dobbie M, Fitzpatrick M, Kent M, Wojtal O'Neill M. Improving preprocedure time out compliance using remote audiovisual observation. AORN J. 2019; 109:(6)748-755

Finch EP, Langston M, Erickson D, Pereira K. Debriefing in the OR: a quality improvement project. AORN J. 2019; 109:(3)336-344

Georgiou E, Mashini M, Panayiotou I Barriers and facilitators for implementing the WHO's safety surgical checklist: a focus group study among nurses. J Perioper Pract. 2018; 28:(12)339-346

Gillespie BM, Steel C, Kang E Evaluation of a brief team training intervention in surgery: a mixed-methods study. AORN J. 2017; 106:(6)513-522

Gillespie BM, Harbeck EL, Lavin J Evaluation of a patient safety programme on Surgical Safety Checklist compliance: a prospective longitudinal study. BMJ Open Qual. 2018; 7:(3)

Gitelis ME, Kaczynski A, Shear T Increasing compliance with the World Health Organization Surgical Safety Checklist—a regional health system's experience. Am J Surg. 2017; 214:(1)7-13

Mortality of emergency abdominal surgery in high, middle- and low-income countries. Br J Surg. 2016; 103:(8)971-988

Health Service Executive. Serious reportable events. HSE implementation guidance document. 2015. (accessed 7 November 2022)

Hellar A, Tibyehabwa L, Ernest E A team-based approach to introduce and sustain the use of the who surgical safety checklist in Tanzania. World J Surg. 2020; 44:(3)689-695

Hicks D, Lee J, Berson M, Bolick C, Diem R. Guidelines for using technology to prepare social studies teachers. Contemp Issues in Technology and Teacher Education. 2014; 14:(4)433-450

Jones B, Vaux E, Olsson-Brown A. How to get started in quality improvement. BMJ. 2019; 364

Korkiakangas T. Mobilising a team for the WHO Surgical Safety Checklist: a qualitative video study. BMJ Qual Saf. 2017; 26:(3)177-188

Mahmood T, Mylopoulos M, Bagli D, Damignani R, Aminmohamed Haji F. A mixed methods study of challenges in the implementation and use of the surgical safety checklist. Surgery. 2019; 165:(4)832-837

McCulloch P, Morgan L, New S Combining systems and teamwork approaches to enhance the effectiveness of Safety improvement interventions in Surgery. Ann Surg. 2017; 265:(1)90-96

NHS England. Decade of improved outcomes for patients thanks to Surgical Safety Checklist. 2019. (accessed 7 November 2022)

NHS England/NHS Improvement. Never Events reported as occurring between 1 April 2019 and 31 March 2020 – final update. 2020. (accessed 7 November 2022)

O'Brien B, Graham MM, Kelly SM. Exploring nurses' use of the WHO safety checklist in the perioperative setting. J Nurs Manag. 2017; 25:(6)468-476

Rakoff D, Akella K, Guruvegowda C, Chhajwani S, Seshadri S, Sola S. Improved compliance and comprehension of a surgical safety checklist with customised versus standard training: a randomized trial. J Patient Saf. 2018; 14:(3)138-142

Röhsig V, Maestri RN, Parrini Mutlaq MF Quality improvement strategy to enhance compliance with the World Health Organization Surgical Safety Checklist in a large hospital: quality improvement study. Ann Med Surg (Lond). 2020; 55:19-23

Russ S, Rout S, Sevdalis N, Moorthy K, Darzi A, Vincent C. Do safety checklists improve teamwork and communication in the operating room? A systematic review. Ann Surg. 2013; 258:(6)856-871

Saturno PJ, Soria-Aledo V, Da Silva Gama ZA, Lorca-Parra F, Grau-Polan M. Understanding WHO surgical checklist implementation: tricks and pitfalls. An observational study. World J Surg. 2014; 38:(2)287-295

Schwendimann R, Blatter C, Lüthy M Adherence to the WHO surgical safety checklist: an observational study in a Swiss academic center. Patient Saf Surg. 2019; 13

Shear T, Deshur M, Avram MJ Procedural timeout compliance is improved with real-time clinical decision support. J Patient Saf. 2018; 14:(3)148-152

Verwey S, Gopalan PD. An investigation of barriers to the use of the World Health Organization Surgical Safety Checklist in theatres. S Afr Med J. 2018; 108:(4)336-341

Weiser TG, Haynes AB, Molina G Size and distribution of the global volume of surgery in 2012. Bull World Health Organ. 2016; 94:(3)201-209F

World Health Organisation Surgical Safety Checklist. 2016. (accessed 7 November 2022)

World Health Organization. WHO Surgical safety checklist: adaptation guide. 2008. (accessed 7 November 2022)

World Health Organization. WHO Surgical Safety Checklist. 2009. (accessed 7 November 2022)

Yu X, Huang Y, Guo Q Relaunch and Implementation of Operating Room Surgical Safety Checklist (RIORS) study group. Clinical motivation and the surgical safety checklist. Br J Surg. 2017; 104:(4)472-479

Ziman R, Espin S, Grant RE, Kitto S. Looking beyond the checklist: an ethnography of interprofessional operating room safety cultures. J Interprof Care. 2018; 32:(5)575-583

Factors that enhance compliance with the Surgical Safety Checklist

24 November 2022
Volume 31 · Issue 21



The World Health Organization (WHO) has reported that its Surgical Safety Checklist (SSC) has resulted in significant reductions in morbidity and mortality. Despite its proven success, meaningful compliance with the Surgical Safety Checklist initiative has been low.


The authors sought to identify and explore published research on factors that enhance compliance with the SSC within surgical team members.


A review of the literature published between January 2017 and January 2021 was undertaken. Six databases were searched, and 1340 studies were screened for eligibility. The 17 studies included were critically appraised using the Crowe Critical Appraisal Tool.


Three main themes were identified: training and innovations; process adaptations and team leadership.


This review of the literature draws attention to the complexities of checklist compliance and identifies the need for training, leadership and adaptation to new safety processes.

Annually, more than 300 million surgical procedures are performed worldwide (Weiser et al, 2016). Although the majority have the desired patient outcome with no adverse events, errors still occur. Surgery is associated with two thirds of in-hospital adverse events (de Vries et al, 2010). The Surgical Safety Checklist (SSC) was introduced by the World Health Organization (WHO) (2009) to address patient safety, ineffective communication and eliminate memory-dependent errors. Figure 1 outlines the key components of the SSC (WHO, 2009). The checklist, which has undergone minor revisions by the WHO, and has been adapted for use in England and Wales and is widely used in Ireland, is divided into three sections:

Checklists assist with the delivery of skilled care and can been seen as one of the greatest technical advances in surgical safety this century (Gillespie et al, 2018). Both early research and follow-up studies reported a reduction in mortality when the checklist was used effectively (Bergs et al, 2014; GlobalSurg Collaborative, 2016). The SSC has received worldwide acclaim and is currently used in 132 countries (Gillespie et al, 2018; NHS England, 2019). Safety checklists improve surgical safety through fostering better inter-professional teamwork and communication (Russ et al, 2013).

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