Patient safety

Safe Surgery Saves Lives Frequently Asked Questions

We are pleased to see that you are interested in our efforts to improve global surgical safety. The first part of this section is designed to answer some general questions you may have about the Checklist and the Safe Surgery Saves Lives initiative. Once you have read these, or if you’re already interested in using the Checklist at your institution, we invite you to read the second section which addresses a number of questions frequently asked by those individuals interested in implementing the Checklist. You may also download a PDF of these questions if you prefer.

Background FAQ

Q1: Why is the Checklist important?

A: 234 million major operations are performed annually across the world. This translates to roughly one operation per every 25 people and indicates that the safety of care is of significant public health importance. For more on this statistic and its implications, see our article in the Lancet:

Moreover, given previously estimated rates of major complication and death following inpatient surgery, we have postulated that – even using conservative estimates – 7 million patients suffer complications following surgery, half of which are likely to be preventable.

Q2: What is the Checklist and how was the Checklist developed?

A: The WHO Safe Surgery Saves Lives Checklist was created by an international group of experts gathered by the WHO with the goal of improving the safety of patients undergoing surgical procedures around the globe. Input from anesthesiologists, operating theatre nurses, surgeons, patients and other professionals was used in the development of this tool. Both small and large scale clinical testing of the checklist has been performed culminating in a multi-site pilot study with results published in the New England Journal of Medicine in January 2009:

In sites that ranged from small district hospitals to large medical centers in diverse geographical settings, the use of a 19-item checklist was demonstrated to reduce the complications and mortality associated with a variety of surgical procedures by greater than 30 percent. The checklist has been designed to be simple to use and applicable in many settings. It is currently in active use in operating rooms around the world.

Q3: What does the Checklist involve? How will it impact surgical practices?

A: The Checklist involves the coordination of the operating team – the surgeons, anesthesia providers, and nurses – to discuss key safety checks prior to specific phases of perioperative care: a “Sign In” prior to induction of anesthesia, a “Time Out” prior to skin incision, and a “Sign Out” before the team leaves the operating room. Many of the checks are already routine in some institutions, but surprisingly, few operating teams accomplish them all consistently, even in the most advanced settings. In our pilot study, we were able to show that use of the checklist increases adherence to safety standards and reduces the rate of complications and mortality associated with surgical care.

Q4: Don't hospitals already use Checklists?

A: Many hospitals do already have checks in place, but their consistent use is dismayingly variable. Many developed settings perform a “Time Out” where the team confirms the patient identity, procedure, and site of operation. Teams are using this time to perform and expand briefing, but this has never been elaborated to the extent that the Safe Surgery Saves Lives project has done.

Q5: How do you know the Checklist works?

A: Between October 2007 and September 2008, we studied the effects of the checklist in eight hospitals in eight cities (Toronto, Canada; New Delhi, India; Amman, Jordan; Auckland, New Zealand; Manila, Philippines; Ifakara, Tanzania; London, England; and Seattle, WA) representing a variety of economic circumstances and diverse populations of patients. We prospectively collected data on clinical processes and outcomes from 3733 patients before and 3955 patients after the checklist was implemented. The results of the study were published in the New England Journal of Medicine on January 29, 2009 and demonstrated dramatic improvements in both processes and outcomes. Indeed, use of the checklist reduced the rate of deaths and complications by more than one third across all 8 pilot hospitals. The rate of major inpatient complications dropped from 11% to 7%, and the inpatient death rate following major operations fell from 1.5% to 0.8% after implementation of the checklist. Moreover, the effect was of similar magnitude in both high and low/middle income country sites. Even our site in rural Tanzania was able to implement the checklist and see substantial improvements in outcomes, all at essentially no cost to the system.

Q6: What has been the response to the Checklist?

A: To date, more than 300 professional societies, health organizations, ministries, and NGOs have endorsed the concept of the Safe Surgery Saves Lives Program. The task of the program now is to build on this momentum and the information we gathered during the pilot study to promote the widespread use, implementation, and dissemination of the Checklist as a safety practice in every operation. Participating hospitals are encouraged to register with WHO:

Dissemination progress can be tracked through our interactive online map:

Q7: Does the Checklist apply to all settings? How does it impact developed and developing regions differently?

A: The most developed countries tend to have well established and codified guidelines for the process of care during the perioperative period, although these are often inconstantly applied. Other settings may lack clear guidelines and policies for directing the perioperative process. The guidelines and Checklist can help countries and facilities evaluate their own processes of care and improve surgical safety. Moreover, even in the developed world, there is variability in adhering to basic safety practices .