Surgical Safety Checklist still faces implementation challenges 10 years later

A decade after the development of the Surgical Safety Checklist (SSC), data and anecdotal evidence reveals that mortality rates have been reduced at sites that successfully adopt it, but implementation challenges remain a barrier to more widespread use of the checklist.

Atul A. Gawande, MD, MPH, FACS, who founded Ariadne Labs at Brigham and Women’s Hospital and Harvard, helped develop the checklist, which was adopted in 2008 by the World Health Organization in a global effort to standardize safety measures in operating rooms. In agreeing to create the checklist, Dr. Gawande not only wanted to develop standards of care, he also wanted to focus on implementation.

“Our usual way of dealing with delivery of better ideas in health care has been first to say, ‘Let’s teach people the right thing to do,’” said Dr. Gawande, a general and endocrine surgeon at Brigham and Women’s Hospital, Boston, MA. “Then when we’re frustrated that we’re not getting the results we need, we start saying, ‘Well, let’s mandate that people do the right thing.’ That’s where you get stacks of guidelines, but you don’t get tremendous amounts of change.”

Data from sites that have adopted the 19-step checklist reflect this. In a pilot study of preselected sites that were “enthusiastic” about implementing the checklist and received weekly support from the Ariadne team, 47 percent of the sites had a decrease in mortality after implementation. At surgical sites in Scotland and France where the checklist was mandated and team members received regular feedback, mortality declined 26 percent and 35 percent, respectively. At other sites where the checklist was simply mandated with no regular feedback, there was no reduction in mortality.

Adriana M. Serna Lozano, MD
Adriana M. Serna Lozano, MD

The SSC, which identifies three critical pause points in surgery (before the induction of anesthesia, before the incision in the skin, and before the patient leaves the operating room), encourages communication and teamwork to help reduce surgical errors. However, it can take time to create a team-oriented culture among surgeons who have different values, Dr. Gawande said.

“It’s an approach that requires you to work with different values, humility, discipline, and teamwork,” he said.

Adriana M. Serna Lozano, MD, general and thoracic surgeon, Clínica El Country, Colsanitas, Bogotá, Colombia, reviewed challenges associated with implementing the checklist in Colombia. Those challenges included major trauma, busy days, frequent staff changes, and getting people to speak up.

“The challenge here is to avoid emergencies,” Dr. Serna Lozano said. “Everybody has to be ready for the emergencies, especially in trauma, and we have to be prepared for busy days.”


King-David Terna Yawe, MD, FWACS, FICS, FISS, FIICA, MNIM
King-David Terna Yawe, MD, FWACS, FICS, FISS, FIICA, MNIM

King-David Terna Yawe, MD, FWACS, FICS, FISS, FIICA, MNIM, University of Abuja and University of Abuja Teaching Hospital, Nigeria, discussed the overall status of SSC implementation and offered future recommendations. Knowledge and awareness of the checklist is generally high, he said, but implementation has been slow and inadequate in many settings. Implementation has been better in high-income countries, he noted. In low-income countries, implementation challenges include lack of cooperation from team members, workforce shortages, equipment and infrastructure limitations, and lack of patient care protocols.

Dr. Yawe said strong local leadership, training workshops, and monthly feedback meetings would foster better implementation. “Also, tailoring the checklist specifically to accommodate cultural differences and local practices,” he said.

For more information about the Surgical Safety Checklist, visit

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