Implementation of WHO Surgical Safety Checklist in Assessing Surgical Mortality, Morbidity and Length of Hospital Stay

  • Parth Dhamija Junior Resident, Department of Surgery, Government Medical College & Rajindra Hospital, Patiala, Punjab, India.
  • Manisha Aggarwal Senior Resident, Department of Surgery, Government Medical College & Rajindra Hospital, Patiala, Punjab, India.
  • Rachan Lal Singla Associate Professor, Department of Surgery, Government Medical College & Rajindra Hospital, Patiala, Punjab, India.
  • Ashwani Kumar Professor & Head, Department of Surgery, Government Medical College & Rajindra Hospital, Patiala, Punjab, India.
Keywords: WHO, Surgical Safety, Mortality, Morbidity, Hospital Stay.


Background: In the era of quality assurance, strategy development to overcome avoidable human errors has become imperative. One of the most important goals for healthcare organizations is patient safety. Studying of four pillars of safe surgical care: infection prevention, anaesthesia safety, team work and communication, and measurement of surgical capacity and outcomes resulted in the development of WHO Surgical Safety Checklist (SSC) in June 2008. The present study was conducted to assess the surgical morbidity, mortality, length of hospital stay and quality of life after routine implementation of the WHO Surgical Safety Checklist on patient’s undergoing major operative procedure.

Materials and Methods : This was a prospective study which included 50 cases (Group A) on which the checklist was applied and 50 controls (Group B) on which the checklist was not applied in the Department of General Surgery at Government Medical College and Rajindra Hospital, Patiala during the period of May 2019 to December 2020.

Results : The study has shown an overall decrease in complication rates from 58% to 22% after the implementation of the checklist. Wound discharge showed a decrease from 34% to 16% whereas rates of wound dehiscence decreased by 18% after the implementation of the checklist. Surgical Site Infection (SSI), one of the most common complications seen in surgical wards showed significant decrease with p-value = 0.037. Mortality rates also showed a decrease by 2% post-implementation of the checklist. The mean hospital stay, however, showed non-significant results with stay decreasing from 9.40 days to 8.70 days post-implementation. Successful communication was observed after checklist implementation (Anaesthesiologists: 78.12% vs. 93.75%; Surgeons: 88.46% vs. 94.87%; Circulating Nurses: 70.0% vs. 82.5%)

Conclusion: It can be concluded from our study that effective implementation of the checklist improves communication and teamwork, decreases the occurrence of adverse events both intra-operatively and post-operatively and subsequently improving patient’s quality of life.


Download data is not yet available.


1. Debas HT, Gosselin R, McCord C, Thind A. Surgery. In: Jamison DT, Breman JG, Measham AR, et al., eds. Disease control priorities in developing countries. 2nd ed. Disease Control Priorities Project. Washington, DC: International Bank for Reconstruction and Development/World Bank, 2006:1245-60.
2. Alnaib M, Samaraee AA, Bhattacharya V. The WHO surgical safety checklist: a review. Journal of perioperative practice. 2012 Sep;22(9):289-92.
3. Weiser TG, Regenbogen SE, Thompson KD, et al. An estimation of the global volume of surgery: a modelling strategy based on available data. Lancet 2008; 372: 139-44.
4. Leonard M, Graham S, Bonacum D. The human factor: the critical importance of effective teamwork and communication in providing safe care. BMJ Quality & Safety. 2004 Oct 1;13(suppl 1):i85-90.
5. Kilo CM. A framework for collaborative improvement: lessons from the Institute for Healthcare Improvement's Breakthrough Series. Quality management in health care. 1998 Sep 1;6:1-4.
6. Monk TG, Saini V, Weldon BC, Sigl JC. Anesthetic management and one-year mortality after noncardiac surgery. Anesthesia & Analgesia. 2005 Jan 1;100(1):4-10
7. Liem BJ, Holland JM, Kang MY, Hoffelt SC, Marquez CM. Karnofsky Performance Status assessment: resident versus attending. Journal of Cancer Education. 2002 Sep 1;17(3):138-41.
8. Keats AS. The ASA classification of physical status–a recapitulation. The Journal of the American Society of Anesthesiologists. 1978 Oct 1;49(4):233-5.
9. Le Gall JR, Lemeshow S, Saulnier F. A new simplified acute physiology score (SAPS II) based on a European/North American multicenter study. JAMA. 1993 Dec 22;270(24):2957-63.
10. Le Gall JR, Klar J, Lemeshow S, Saulnier F, Alberti C, Artigas A, Teres D. The Logistic Organ Dysfunction system: a new way to assess organ dysfunction in the intensive care unit. JAMA. 1996 Sep 11;276(10):802-10.
11. Papaconstantinou HT, Smythe WR, Reznik SI, Sibbitt S, Wehbe-Janek H. Surgical safety checklist and operating room efficiency: results from a large multispecialty tertiary care hospital. The American Journal of Surgery. 2013 Dec 1;206(6):853-60.
12. Haynes AB, Weiser TG, Berry WR, Lipsitz SR, Breizat AH, Dellinger EP, Herbosa T, Joseph S, Kibatala PL, Lapitan MC, Merry AF. A surgical safety checklist to reduce morbidity and mortality in a global population. New England journal of medicine. 2009 Jan 29;360(5):491-9.
13. Van Klei WA, Hoff RG, Van Aarnhem EE, Simmermacher RK, Regli LP, Kappen TH, Van Wolfswinkel L, Kalkman CJ, Buhre WF, Peelen LM. Effects of the introduction of the WHO “Surgical Safety Checklist” on in-hospital mortality: a cohort study. Annals of surgery. 2012 Jan 1;255(1):44-9.
14. Russ S, Rout S, Sevdalis N, Moorthy K, Darzi A, Vincent C. Do safety checklists improve teamwork and communication in the operating room? A systematic review. Annals of surgery. 2013 Dec 1;258(6):856-71.
15. Eappen S, Lane BH, Rosenberg B, Lipsitz SA, Sadoff D, Matheson D, Berry WR, Lester M, Gawande AA. Relationship between occurrence of surgical complications and hospital finances. JAMA. 2013 Apr 17;309(15):1599-606.
16. Sewell M, Adebibe M, Jayakumar P, Jowett C, Kong K, Vemulapalli K, Levack B. Use of the WHO surgical safety checklist in trauma and orthopaedic patients. International orthopaedics. 2011 Jun;35(6):897-901.
17. Thomassen Ø, Storesund A, Søfteland E, Brattebø G. The effects of safety checklists in medicine: a systematic review. Acta Anaesthesiologica Scandinavica. 2014 Jan;58(1):5-18.
18. Semel ME, Resch S, Haynes AB, Funk LM, Bader A, Berry WR, Weiser TG, Gawande AA. Adopting a surgical safety checklist could save money and improve the quality of care in US hospitals. Health Affairs. 2010 Sep 1;29(9):1593-9.
19. Haynes AB, Weiser TG, Berry WR, Lipsitz SR, Breizat AH, Dellinger EP, Dziekan G, Herbosa T, Kibatala PL, Lapitan MC, Merry AF. Changes in safety attitude and relationship to decreased postoperative morbidity and mortality following implementation of a checklist-based surgical safety intervention. BMJ quality & safety. 2011 Jan 1;20(1):102-7.
20. Conley DM, Singer SJ, Edmondson L, Berry WR, Gawande AA. Effective surgical safety checklist implementation. Journal of the American College of Surgeons. 2011 May 1;212(5):873-9.
21. Aveling EL, McCulloch P, Dixon-Woods M. A qualitative study comparing experiences of the surgical safety checklist in hospitals in high-income and low-income countries. BMJ open. 2013 Aug 1;3(8).
22. Russ SJ, Sevdalis N, Moorthy K, Mayer EK, Rout S, Caris J, Mansell J, Davies R, Vincent C, Darzi A. A qualitative evaluation of the barriers and facilitators toward implementation of the WHO surgical safety checklist across hospitals in England: lessons from the “Surgical Checklist Implementation Project”. Annals of surgery. 2015 Jan 1;261(1):81-91.
23. Whyte S, Lingard L, Espin S, Baker GR, Bohnen J, Orser BA, Doran D, Reznick R, Regehr G. Paradoxical effects of interprofessional briefings on OR team performance. Cognition, Technology & Work. 2008 Oct;10(4):287-94.
24. Rydenfält C, Johansson G, Odenrick P, Åkerman K, Larsson PA. Compliance with the WHO Surgical Safety Checklist: deviations and possible improvements. International Journal for Quality in Health Care. 2013 Apr 1;25(2):182-7.
25. Gawande AA, Thomas EJ, Zinner MJ, Brennan TA. The incidence and nature of surgical adverse events in Colorado and Utah in 1992. Surgery 1999; 126:66-75.
26. Helmiö P, Blomgren K, Takala A, Pauniaho SL, Takala RS, Ikonen TS. Towards better patient safety: WHO Surgical Safety Checklist in otorhinolaryngology. Clinical otolaryngology. 2011 Jun;36(3):242-7.
27. Kearns RJ, Uppal V, Bonner J, Robertson J, Daniel M, McGrady EM. The introduction of a surgical safety checklist in a tertiary referral obstetric centre. BMJ quality & safety. 2011 Sep 1;20(9):818-22.
28. Vogts N, Hannam JA, Merry AF, et al. Compliance and quality in administration of a Surgical Safety Checklist in a tertiary New Zealand hospital. N Z Med J 2011;124:48–58.
29. Takala RS, PAUNIAHO SL, Kotkansalo A, Helmiö P, Blomgren K, Helminen M, Kinnunen M, Takala A, Aaltonen R, Katila AJ, Peltomaa K. A pilot study of the implementation of WHO S urgical C hecklist in Finland: improvements in activities and communication. Acta anaesthesiologica Scandinavica. 2011 Nov;55(10):1206-14.
30. Pérez-Guisado J, de Haro-Padilla JM, Rioja LF. Implementation of the World Health Organization Surgical Safety Checklist in plastic and reconstructive patients. Plastic and reconstructive surgery. 2012 Mar 1;129(3):600e-2e.
31. Kasatpibal N, Senaratana W, Chitreecheur J, Chotirosniramit N, Pakvipas P, Junthasopeepun P. Implementation of the World Health Organization surgical safety checklist at a university hospital in Thailand. Surgical infections. 2012 Feb 1;13(1):50-6.
32. Patel A, Sanghi V, Gupta VR. Implementation of surgical safety checklist for all invasive procedures. The Journal of National Accreditation Board for Hospitals & Healthcare Providers. 2015 Jul 1;2(2):41.
33. Weiser TG, Haynes AB, Dziekan G, Berry WR, Lipsitz SR, Gawande AA. Effect of a 19-item surgical safety checklist during urgent operations in a global patient population. Annals of surgery. 2010 May 1;251(5):976-80.
34. de Vries EN, Prins HA, Crolla RM, den Outer AJ, van Andel G, van Helden SH, Schlack WS, van Putten MA, Gouma DJ, Dijkgraaf MG, Smorenburg SM. Effect of a comprehensive surgical safety system on patient outcomes. New England Journal of Medicine. 2010 Nov 11;363(20):1928-37.
35. Sewell M, Adebibe M, Jayakumar P, Jowett C, Kong K, Vemulapalli K, Levack B. Use of the WHO surgical safety checklist in trauma and orthopaedic patients. International orthopaedics. 2011 Jun;35(6):897-901.
36. Borchard A, Schwappach DL, Barbir A, Bezzola P. A systematic review of the effectiveness, compliance, and critical factors for implementation of safety checklists in surgery. Annals of surgery. 2012 Dec1;256(6):925-33.
37. Urbach DR, Govindarajan A, Saskin R, Wilton AS, Baxter NN. Introduction of surgical safety checklists in Ontario, Canada. N Engl J Med. 2014 Mar 13;370:1029-38.
38. Haugen AS, Søfteland E, Almeland SK, Sevdalis N, Vonen B, Eide GE, Nortvedt MW, Harthug S. Effect of the World Health Organization checklist on patient outcomes: a stepped wedge cluster randomized controlled trial. Annals of surgery. 2015 May 1;261(5):821-8.
39. Rodrigo-Rincon I, Martin-Vizcaino MP, Tirapu-Leon B et al (2015). The effects of surgical checklists on morbidity and mortality: a pre- and post-intervention study. Acta Anaesthesiologica Scandinavica. 2015 Feb;59(2):205-14.
40. Chaudhary N, Varma V, Kapoor S, Mehta N, Kumaran V, Nundy S. Implementation of a surgical safety checklist and postoperative outcomes: a prospective randomized controlled study. Journal of Gastrointestinal Surgery. 2015 May;19(5):935-42.
41. Wang H, Zheng T, Chen D, Niu Z, Zhou X, Li S, Zhou Y, Cao S. Impacts of the surgical safety checklist on postoperative clinical outcomes in gastrointestinal tumor patients: A single-center cohort study. Medicine. 2019 Jul;98(28).
42. De Jager E, Gunnarsson R, Ho YH. Implementation of the World Health Organization Surgical Safety Checklist correlates with reduced surgical mortality and length of hospital admission in a high-income country. World journal of surgery. 2019 Jan 15;43(1):117-24.
43. Rodella S, Mall S, Marino M, Turci G, Gambale G, Montella MT, Bonilauri S, Gelmini R, Zuin P. Effects on clinical outcomes of a 5-year surgical safety checklist implementation experience: a large-scale population-based difference-in-differences study. Health services insights. 2018 Jul 20;11:1178632918785127.
How to Cite
Dhamija P, Aggarwal M, Singla RL, Kumar A. Implementation of WHO Surgical Safety Checklist in Assessing Surgical Mortality, Morbidity and Length of Hospital Stay. Int Arch BioMed Clin Res [Internet]. 2021Oct.9 [cited 2022May28];7(3):GS1-GS4. Available from: