If surgery has become an essential part of enabling human beings to live long and healthy lives, then the World Health Organization (WHO) Surgical Safety Checklist has become an essential part of enabling safe surgery.
On January 15, 2020, Lifebox, the global safe-surgery non-profit and long-time ESA partner, and Ariadne Labs, a centre for health systems innovation at Harvard University, released “Checking In On the Checklist,” a report – and an accompanying series of studies. Featured in The New York Times, the report analyses the global uptake of the WHO Surgical Safety Checklist since its launch ten years ago and recommends ways it can be more effectively used to improve surgical safety for millions at risk.
Developed by a global WHO process chaired by Dr Atul Gawande, the 19-item Checklist was designed to be simple, widely applicable, and reduce meaningful patient harm in the operating room. In 2008, a pilot study analysed the impact of the Checklist across 8 high-, middle-, and low-resource settings and found that effective Checklist use was associated with a decrease in postoperative mortality of nearly 50%. As Dr Isabeau Walker, an anaesthesiologist at Great Ormond Street Hospital and Lifebox board member, described, “the Checklist completely changed the operating room; it changed it beyond recognition. It introduced communication within teams and a culture of safety.”
The Checklist at Ten Years
The Checking In On the Checklist report found that the Checklist is referenced by at least 139 (70%) of the world’s countries and is included as a national standard by the health ministries of at least 20 countries. The report describes how this happened largely organically, through trials and errors of passionate early adopters and support by the growth of a vast global network of researchers and implementers devoted to building an evidence base.
The report also notes that although the spread of the Checklist has been broad, its uptake and use remains variable. One article in the series associated with the Checking in on the Checklist report – published recently in the British Journal of Surgery – found that worldwide Checklist use is overall high. Pooled analysis of international studies of more than 85,000 patients in 94 countries showed its use in 75% of operations globally in 2014-2016. However, in the low middle- and low-HDI countries, the Checklist was used in only 60.4% and 29.8% of operations, respectively.
As described by Donald McNeil in a New York Times article featuring the report, the reasons behind this lag are many. Surgical teams operating under emergent conditions are less likely to use the Checklist, as are countries where the commonly spoken language is not of the six official WHO languages (Arabic, Chinese, English, French, Russian, Spanish). Entrenched hierarchies, perceived impact on workload or workflow disruptions, or outspoken, unsupportive surgeons serve as major barriers to Checklist use.
Unfinished Business in Low- and Middle-Income Countries
Checking In On the Checklist also offers a set of key recommendations on improving Checklist uptake and use, particularly in low- and middle-income countries. Getting buy-in from local medical leaders and surgical team members, adapting the Checklist to local needs including language translation and modification to fit local practices and resources, and maintaining support by top-down management and bottom-up staff to ensure that the Checklist is indeed being used have proven to be essential strategies for introducing and maintaining the long-term use of the Checklist.
As Dr Nina Capo-Chichi, an anaesthesiologist for Benin who supported Checklist implementation at her facility and beyond with Mercy Ships, states, the WHO Surgical Safety Checklist is an essential part of enabling safe surgery: “in those places that have adopted the Checklist, there is now a way to speak about safety that was never there before. They count instruments. They count swabs. We wanted people to start thinking about safety, and they have.”