SCP: WHO Surgical Safety Checklist Short description of the SCP and information on implementation


The WHO Surgical Safety Checklist is a perioperative checklist which is intended to ensure safe surgery and to minimize complications (Haynes et al 2009). Due to its generic nature, the WHO Surgical Safety Checklist is applicable to a variety of settings and health care systems (Borchard et al 2012).

Health care organisations (HCOs) which will implement this SCP within Work Package 5 of the PaSQ Project are expected to apply the WHO Surgical Safety Checklist with the following three phases for surgical patients (WHO 2009b, AHRQ 2013):

1. Before induction of anesthesia (“Sign In”),

  • with at least nurse and anaesthetist, further operating team members could be involved,
  • covering areas such as patient identification, site marking and anaesthesia equipment check

2. Before skin incision (“Time Out”),

  • with nurse, anaesthetist and surgeon, further operating team members could be involved,
  • covering areas such as team introductions, review of critical steps, and antibiotic prophylaxis

3. Before patient leaves operating room (“Sign Out”),

  • with nurse, anaesthetist and surgeon, further operating team members could be involved,
  • covering areas such as checking counts of instruments, specimen labeling, and concerns for recovery

The following information contains additional (optional) guidance for HCOs implementing the WHO Surgical Safety Checklist:

  • The checklist should be locally adapted to take into account differences among facilities with respect to their processes, the culture of their operating rooms and the degree of familiarity each team member has with each other (WHO 2009c).
  • Removing items because they cannot be fulfilled in the existing environment or circumstances is strongly discouraged. Operating teams may consider adding other safety checks for specific procedures – e.g. regarding medical means such as heparin or warfarin (WHO 2009c).
  • Principles for modifying the WHO Surgical Safety Checklist (WHO 2008):
  • Focused – The checklist should be concise, addressing those issues that are most critical and not effectively checked by other safety mechanisms. Ideally, there should be five to nine items in each phase of the checklist.
  • Brief – It should take no more than a minute to complete each phase of the checklist.
  • Actionable – Every checklist item should be linked to a specific, directly associated action so that the surgical team members know exactly what they are expected to do.
  • Verbal – The checklist is intended to promote and guide a verbal interaction among the surgical team members.
  • Collaborative – The modification of the checklist should be done in collaboration with representatives from groups who might be involved in its use. This is also important for creating the feeling of “ownership” which is central to adoption and permanent change in practice.
  • Tested – Prior to rollout of a modified checklist, it should be tested e.g. through a simulation (running through the checklist with operating team members sitting around a table) and through a use for a single day by a single operating team in order to collect feedback. This process should be continued until the operating team is comfortable that the checklist works in the given environment.
  • Integrated – Many institutions already have strategies that ensure the reliable execution of many of the processes which are part of the WHO Surgical Safety Checklist. Integrating new safety checks into the processes is a challenge but possible in nearly all settings. The major additions include the integration of team communication, briefings as well as debriefing. These items are of critical importance and should not be deleted from the checklist.
  • Logistic considerations: For some HCOs, it could be useful to incorporate the checklist in the existing system of the HCO or adjusted in the flow of care. For other HCOs, it could be essential that the checklist is short, simple and straightforward (Borchard et al 2012).
  • In addition to the logistic considerations, other factors exist that may increase the successful implementation in the HCOs, e.g., to hang a poster in every operation room with the aim of facilitating the whole team viewing the checklist and becoming familiar with it; to display a checklist screen saver on all computer screens for many weeks (Borchard et al 2012).
  • The success of the checklist implementation is much higher when it is managed by a multidisciplinary team which meets regularly as well as spontaneously, than when the implementation is managed by a single member of the surgical staff (Borchard et al 2012).
  • Training sessions of checklist use are platforms where common causes of surgical adverse events can be discussed, as well as “how” the checklist has to be conducted to prevent those events and to answer any questions around these topics (Sewell et al 2011, Borchard et al 2012).
  • Involving patients enhances the effectiveness of this practice. For example, patients should be actively engaged in the informed consent process, identity verification and surgical site marking, and be educated about the risks and what to look for. It is very important to inform patients about the checklist use and its intention; otherwise, some patients could perceive questions like “What’s your name?” or “What is the site of your surgery?” as a lack of professionalism or even daunting (Borchard et al 2012).