WHO Surgical Checklist

• Customized Checklist Versions

Both the California Hospital Patient Safety Organization and the California Hospital Association consider the improvement of surgical safety as essential to public health and endorse the concept of the “WHO Surgical Safety Checklist.”

World-wide, about 234,000,000 major operations are performed every year. From those procedures, over 7,000,000 people experience disabling complications, and more than 1,000,000 die.

Surgical care is complex and involves dozens of steps that must be optimized for individual patients. In order to effectively minimize unnecessary loss of life and serious complications, operative teams have ten basic and essential objectives in any surgical case, which the WHO Safe Surgery Guidelines aim to support:

1. The team will operate on the correct patient at the correct site.
2. The team will use methods known to prevent harm from anesthetic administration, while protecting the patient from pain.
3. The team will recognize and effectively prepare for life-threatening loss of airway or respiratory function.
4. The team will recognize and effectively prepare for risk of high blood loss.
5. The team will avoid inducing any allergic or adverse drug reaction known to be a significant risk for the patient.
6. The team will consistently use methods known to minimize risk of surgical site infection.
7. The team will prevent inadvertent retention of instruments or sponges in surgical wounds.
8. The team will secure and accurately identify all surgical specimens.
9. The team will effectively communicate and exchange critical patient information for the safe conduct of the operation.
10. Hospitals and public health systems will establish routine surveillance of surgical capacity, volume, and results.

Improved teamwork and communication is one of the main goals for using a checklist. Many hospitals are already doing most of the items on the list but not reviewing them as a team. If there is no designated point when these items are reviewed, it is common to find that they are verified most of the time, but not every time, i.e., not reliably.

The checklist reduces the chance of overlooking important information at three points during the patient’s care: at check-in, at the time-out, and at the end of the case. The majority of the activities on the checklist are already implemented in most USA hospitals, and most already have checklists for a portion of the patient’s care (particularly check-in), so this should not represent a major change in practice patterns, but would add some rigor to the critical phases, particularly at the end of the case. Certain aspects of the checklist are intended to improve team communication. A world-wide trial in eight very different hospitals exhibited significant reductions in morbidity and mortality at many of the institutions.

The WHO Safe Surgery Saves Lives site includes copies of the checklist, an implementation manual, and tools for training and implementation.

The Checklist, a New Yorker article by Atul Gawande, describes the case for checklists in making complex tasks safer. Dr. Gawande has a book: The Checklist Manifesto: How to Get Things Right, also available as an audio book and an Amazon Kindle edition.

The Joint Commission Universal Protocol for Preventing Wrong Site, Wrong Procedure and Wrong Person Surgery addresses and augments many of the areas covered by the first two stages of the WHO checklist (check-in and time-out). The Joint Commission supports the use of the WHO Surgical Safety Checklist, but, in and of itself the WHO Checklist does not completely address the standards addressed by the Universal Protocol. To assist hospitals, the Hospital Association of Southern California (HASC) researched and developed a template Universal Protocol policy.

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Customized Checklist Versions

General Use

The Association of periOperative Registered Nurses (AORN) has a checklist that includes the Joint Commission’s Universal Protocol. Their version identifies which components come from the WHO Checklist and which from the Joint Commission’s Protocol for Preventing Wrong Site, Wrong Procedure and Wrong Person Surgery™.

Beth Israel Deaconess Hospital has a fully scripted version of the checklist.

Canadian surgical safety checklist. They also have implementation resources.

The Colorado Surgical Site Checklist incorporates Joint Commission and Surgical Care Improvement Project measures.

Oregon Patient Safety Commission version, which includes elements of the Joint Commission-required Universal Protocol, rearranges some of the elements, and adds other safety aspects.

In Washington state, the Surgical Care and Outcomes Assessment Program (SCOAP) has two variations, a surgical checklist and an ambulatory surgery checklist.

Specialized Situations

Children’s Hospital of Boston pediatric surgery checklist.

The Society of Thoracic Surgeons has adapted the WHO checklist for three specific settings: adult cardiac surgery, general thoracic surgery and congenital heart surgery.

The UK National Health Service developed a checklist for cataract surgery and a checklist for radiological interventions.

Checklist Applications

There are even several free iPhone apps: Safe OR: Safety Checklist, Safe Surgery, Surg-i-Scan and Check a Box, Save a Life. Other resources often are the product of provider organizations or expert committees. Apps are not, and an app should be evaluated for accuracy and proper function prior to use.

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