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Systematic review
Surgical safety checklists are an effective means for reducing surgical morbidity and mortality, but have we gone far enough in team-building and leadership to create high reliability?
  1. James Forrest Calland
  1. University of Virginia School of Medicine, Department of Surgery, Charlottesville, Virginia, USA
  1. Correspondence to James Forrest Calland
    MD, FACS, Box 800709 - Dept. Of Surgery, University of Virginia School of Medicine, Charlottesville, VA 22908, USA; calland{at}

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Borchard et al1 have ambitiously reviewed the scientific literature to discern the pooled evidence supporting the use of perioperative surgical safety checklists to improve the safety of operative procedures. In addition, the authors have sought to discern the evidence for engagement of the entire operative team in the process. To date, this has been lacking in the scientific literature, and is perhaps a major weakness in the way that checklists have been implemented.


The authors examined all published trials and cohort studies that investigated the use of checklists between 1995 and 2011. The authors then hand-sorted and referenced the initial hits from their online query to find candidate articles. All studies that use the WHO, SURPASS or the Universal Protocol checklists were included. Relevant studies were excluded if they examined certain aspects only of the checklist process, or individual components of the ‘time out’. A random effects meta-analysis was conducted when two or more of the studies reported a specific outcome.


The main challenge to the generalisability and utility of this study lies with the fact that the meta-analysis that assessed the pooled estimates of efficacy for preventing morbidity and mortality included only three published studies. Nevertheless, the meta-analysis demonstrated a reduced relative risk for perioperative mortality with use of the checklist (0.57), with a concordant morbidity risk reduction (0.62). CIs for both of these estimates were narrow and did not cross the 1.0 line of unity in the accompanying forest plots. Likewise, surgical site infection also demonstrated a greater than 33% risk reduction with the use of checklists.

Compliance was evaluated in 15 studies that used various combinations of observation and staff interviews. To anyone who works in the environment, the results were condemning, but not surprising: compliance with all of the items contained within the checklist resulted in a pooled average estimate of completeness at 75%, but ranged between 20% and 98%. The participation of team members in individual roles varied widely between studies: 67% of surgeons completed the checklist ‘almost always’ but anaesthesiologists did so during only 35% of opportunities.

Qualitative studies and analyses support the opinion that the ‘why’ and ‘how’ of the checklist should be used to ensure effective implementation. The authors, like their predecessors, point out the sad reality that implementation initiatives that focus too much on ‘how’ (and not enough on ‘why’) will likely not produce qualitative or quantitative improvements in practice or safety. The authors further point out that the prevention of surgical adverse events may be concordant with the checklists to reduce the incidence of central venous catheter infections. The multidisciplinary team that rolls out an institutional initiative and follows-up with participants (and outcomes) may be at least as important as the intervention itself.


Though not filled with Earth-shattering new insights or findings, the work of Borchard et al further supports a rising tide of safe surgical practice that includes preoperative safety checklists. What is missing is an acknowledgment of the leadership opportunity that is missed by abdication of the surgeon from the role of initiating and leading the team briefing and associated checklist. The extensive collected works of Helmreich et al2 explore the potential impact of a leadership effect in preventing adverse events in the cockpit of an airplane during simulated mechanical failures and weather events. In short, these researchers observed that the total number of utterances (phrases, words, sentences) initiated by the captain before the flight begins is inversely correlated with the risk of hull loss of the aircraft.3 In the operating room, to surrender the checklist to the circulating nurse (and potentially skip the safety briefing of the surgeon with appropriate statements of goals, objectives, plans, risks and contingencies) is perhaps short-sighted and does not adequately leverage the power of the time out to improve team resilience.

Sadly, perhaps, most of the published work on perioperative safety checklists has relegated the surgeon to the role of passive participant, and in so doing, has ceded ownership of the process to the circulating nurse. Such procedural decisions have resulted in operative teams that are often not very engaged in the WHO checklist/team briefing, and a process that falls apart (in participation and completeness) when the  research team (or administrator) withdraws from the operating theatre.


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  • Competing interests None.