Making Surgery Safer: the WHO Surgical Safety Checklist
Submitting InstitutionImperial College London
Unit of AssessmentClinical Medicine
Summary Impact TypeHealth
Research Subject Area(s)
Medical and Health Sciences: Public Health and Health Services
Summary of the impact
The World Health Organisation's (WHO) Surgical Safety Checklist is the
culmination of over 5 years of concerted research effort to better
understand, model and intervene in human factors that affect clinical
performance and patient safety in operating theatres and surgical care.
Imperial researchers were instrumental in the set up and implementation of
the WHO `Safe Surgery Saves Lives' working group, launched in 2006, from
which the Checklist was a primary outcome. Subsequently, we were
co-investigators, and UK-lead, in a global study the implementation of the
Checklist in 8 pilot hospitals across 7 continents. The Checklist was
demonstrated to significantly improve patient outcomes and was modified
and mandated for use in all NHS surgical procedures in England by the
National Patient Safety Agency. We have since lead a national study that
evaluated the implementation of the Checklist within the NHS and
successfully delivered a team training programme aimed at optimising use
of the Checklist in our hospitals.
Key Imperial College London researchers:
Professor Lord Ara Darzi, Professor of Surgery (1999-present)
Professor Charles Vincent, Professor of Clinical Safety Research
Dr Krishna Moorthy, Clinical Senior Lecturer in Upper Gastrointestinal
Dr Nick Sevdalis, Senior Lecturer (2004-present)
In the past 10 years, patient safety has become an international
priority. Evidence shows that a significant proportion of errors and
adverse events to patients occur in surgical care and, in response to
this, surgical specialties are currently leading the research and clinical
agenda on patient safety. In the UK, the publication of `High Quality Care
for All', government report led by Professor Darzi, (1) placed quality at
the heart of NHS reforms and emphasised the critical role of clinical
leadership in driving safety and quality improvement. This case study
refers to our involvement in the development, validation and evaluation of
the WHO Surgical Safety Checklist prior to its introduction to NHS
surgical services in 2009.
In 2002 the `Clinical Safety Research Unit' was created within the
Department of Surgery and Cancer at Imperial, which in 2007 transitioned
into the significantly larger (in terms of income and FTE) `Imperial
Centre for Patient Safety and Service Quality' (www.cpssq.org),
funded by the National Institute for Health Research (NIHR) — one of only
such centres in the UK. Co-led by Professors Darzi and Vincent, the
Centre for Patient Safety provides an academic base and facilities for
multidisciplinary research and innovations for safer healthcare. This
research group is an international leader in assessing teamwork and
leadership skills scientifically, using extensively validated metrics,
which allow the measurement of these behaviours to be linked to clinical
processes and patient outcomes. Our research group has been at the
forefront of international safety-related research in surgery, with
numerous evidence-based outputs on assessing human behaviour and team
skills in the operating theatre, the surgical environment as a contributor
to error, as well as developing and thoroughly validating interventions
that we have shown enhance surgeons' performance and the safety of
surgical procedures. We have pioneered surgical safety interventions,
including team assessment and training, drawing extensively on similar
applications in high risk industries such as aviation (2, 3).
Based on our track record on surgical safety research, members of our
Department (Dr Moorthy, Professor Darzi) formed part of the WHO's `Safe
Surgery Saves Lives' working group, which formed in 2006 and produced the
WHO Checklist and its study as its main output (4). Professor Darzi also
chaired a surgery sub-theme to identify the evidence based indicators,
which was included in the final checklist.
St Mary's, one of the Imperial NHS Trust hospitals where we are based,
was subsequently selected in 2007 as the lead for the UK for the
international pilot evaluation of the WHO Checklist 5), which was carried
out across eight countries. This pilot study demonstrated significant
improvements in patient outcomes following Checklist implementation
worldwide — including reduction in patient mortality following major
operations from 1.5% to 0.8% and reduction of inpatient complications from
11% to 7% (6).
References to the research
(2) Moorthy, K., Munz, Y., Forrest, D., Pandey, V., Undre, S., Vincent,
C., Darzi, A. (2006). Surgical crisis management skills training and
assessment: A stimulation-based approach to enhancing operating room
performance. Annals of Surgery, 244, 139-147. DOI.
Times cited: 58 (as at 6th November 2013 from ISI Web of
Science). Journal Impact Factor: 6.32.
(3) Sevdalis, N., Lyons, M., Healey, A.N., Undre, S., Darzi, A., Vincent,
C.A. (2009). Observational teamwork assessment for surgery: construct
validation with expert versus novice raters. Ann Surg, 249 (6),
(5) Vats, A., Vincent, C., Nagpal, K., Davies, R.W., Darzi, A., Moorthy,
K. (2010). Practical challenges of introducing WHO surgical checklist: UK
pilot experience. British Medical Journal, 340, b5433. DOI.
Times cited: 40 (as at 6th November 2013 from ISI Web of
Science). Journal Impact Factor: 17.21.
(6) Haynes, A.B., Weiser, T.G., Berry, W.R., Lipsitz, S.R., Breizat,
A.H.S., Dellinger, E.P., Herbosa, T., Joseph, S., Kibatala, P.L., Lapitan,
M.C.M., Merry, A.F., Moorthy, K., Reznick, R.K., Taylor, B., Gawande, A.A.
(2009). A Surgical Safety Checklist to Reduce Morbidity and Mortality in a
Global Population. New England Journal of Medicine, 360, 491-499.
cited: 814 (as at 6th November 2013 from ISI Web of Science).
Journal Impact Factor: 51.65.
• NIHR (2007-2012; £4.5million), Principal Investigators (PIs) A. Darzi
and C. Vincent, Imperial Centre for Patient Safety and Service Quality.
• NIHR (2009-2011; £847,368), PI A. Darzi, Surgical safety: National
quality improvement initiative.
• NIHR (2012-2017; £7.2million), PIs A. Darzi and C. Vincent, Imperial
Patient Safety Translational Research Centre.
Details of the impact
Impacts include: health and welfare, practitioners and services
Main beneficiaries include: patients, health professionals, NHS,
international healthcare providers, WHO, hospital trusts and providers
The WHO Checklist is the single most widely utilised and known patient
safety intervention to be deployed within surgical care since patient
safety became an international priority a decade ago. Following the
findings of the first global health study of the implementation of the WHO
surgical safety checklist, the NHS National Patient Safety Agency (NPSA)
mandated a modified version of the WHO Checklist for use in all surgical
procedures in England, including day surgery in January 2009 . The
Checklist is now part of standard and mandatory operating theatre
procedures in this country. Its direct impact on patient care is enormous:
it reaches 4.6 million surgical patients undergoing an operation annually
in England alone . Further, there are an estimated 234.2 million
surgical patients worldwide , many of whom are positively affected by
the Checklist which as of March 2013 is actively used in 1790 healthcare
organisations worldwide .
To promote the Checklist across the NHS, the NPSA launched a major
implementation campaign known as `Patient Safety First'  to improve the
safety of patients in the NHS. In 2009, our research group undertook the
national `Surgical Checklist Implementation Project' (SCIP ). Funded by
the NIHR and led jointly by Professors Darzi (surgery) and Vincent
(safety), this project brought together surgeons and psychologists aiming
to scientifically study the implementation process of the Checklist across
the NHS, understand its impact on healthcare providers' use of the
Checklist, and derive lessons for the future.
SCIP involved longitudinal data collection over 18 months (2010-11)
across 19 hospitals in England (stratified for location, size, and
teaching vs. community status), surveying more than 3000 NHS personnel,
including observations of over 500 full surgical procedures, and
collecting outcome data from more than 6500 patients . The project data
is currently being prepared for dissemination. The following findings have
- Attitudes towards the Checklist in English hospitals have steadily
improved over time. By the study end (Sept 2011), 74% of operating
theatre staff said they wanted to use the Checklist, 72% believed that
the Checklist makes surgical care safer, and 67% believed that it
improves information transfer in operating theatres.
- The Checklist was used in over 96% of operations. When the Checklist
was not used (particularly its final `Sign-out' part, at the end of a
procedure) there was a trend for increased post-operative complications.
- Teamwork and compliance with standard processes of care (including
antibiotic prophylaxis and patient warming) are significantly higher in
teams who apply the Checklist fully (i.e., all items), who have all team
members present for the Checklist, where all team members pause and,
finally, where surgeons lead the Checklist application.
- A systematic review we carried out as part of SCIP has provided
evidence that use of the Checklist improves teamwork and communication
in the operating theatre when used appropriately without team resistance
Following SCIP, Imperial Healthcare NHS Trust launched a one-year
(2011-12) surgical team training project, led by our research group and
aimed to improve use of the WHO Checklist across our Trust's three
hospitals. The project culminated in modifications to the Checklist (which
were encouraged by its original developers) proposed and led by our
Trust's personnel — the modified Checklist was rolled out to the entire
Trust's surgical services in 2013. Further, local `champions' of surgical
safety have been appointed and regular Checklist audits are now in place.
Our group's research on team working and safety in surgery has been
highlighted twice as research with significant societal impact in the UK
by the Economic and Social Research Council (ESRC). In 2009, our research
on simulation-based training for surgeons, which incorporates training in
the use of the checklist, was selected as an impact case study in the
ESRC's 2009-14 Strategic Plan . In 2011, our research on assessing team
working skills in operating theatres was selected as a case study for
societal impact that highlights the `human element of surgery'.
Sources to corroborate the impact
 National Patient Safety Agency. WHO Surgical Safety Checklist.
Patient Safety Alert PSA002/U1. 2009: http://www.nrls.npsa.nhs.uk/alerts/?entryid45=59860.
Archived on 6th
 Royal College of Surgeons of England. Surgery and the NHS in numbers.
Available at: www.rcseng.ac.uk/media/media-background-briefings-and-statistics/surgery-and-the-nhs-in-numbers.
Archived on 6th
 Weiser, T.G., Regenbogen, S.E., Thompson, K.D., Haynes, A.B.,
Lipsitz, S.R., Berry, W.R., Gawande, A.A. (2008). An estimation of the
global volume of surgery: a modelling strategy based on available data. Lancet,
372 (9633), 139-144. DOI.
 WHO Patient Safety. Surgical safety web map:http://maps.cga.harvard.edu:8080/Hospital/.
Archived on 6th
 NPSA campaign: www.patientsafetyfirst.nhs.uk.
Archived on 6th
 SCIP project: www1.imperial.ac.uk/medicine/about/institutes/patientsafetyservicequality/research_themes_2/c
on 6th November 2013.
 Russ, S., Rout, S., Sevdalis, N., Moorthy, K., Darzi, A., Vincent, C.
(2013). Do safety checklists improve teamwork and communication in the
operating room? A systematic review. Annals of Surgery, DOI.