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Editorial: WHO Surgical Safety Checklist
Pa Patient Saf Advis 2008 Sep;5(3):74. 

On June 25, 2008, the World Health Organization (WHO) launched the Second Global Patient Safety Challenge: Safe Surgery Saves Lives initiative and introduced the “WHO Surgical Safety Checklist.” The checklist is designed to catch omissions in the actions supporting an operation before the patient suffers harm. The “WHO Surgical Safety Checklist” was developed by the World Alliance for Patient Safety under the direction of Atul Gawande, MD, FACS, of Harvard University. It was piloted in eight hospitals on four continents, including the University of Washington. It has been endorsed by more than 200 organizations, including the American College of Surgeons, American Society of Anesthesiologists, Association of periOperative Registered Nurses, American Academy of Orthopaedic Surgeons, American College of Obstetricians and Gynecologists, American Academy of Otolaryngology—Head and Neck Surgery, North American Spine Society, and Council on Surgical and Perioperative Safety. It will be a standard of care in the United Kingdom, Ireland, and Jordan by 2009. Dr. Gawande pointed out that the endorsements covered nations providing surgical care to 75% of the world population.

The checklist has three parts: (1) Sign In, (2) Time Out, and (3) Sign Out. Each part has five to seven items for the operative team to review. 

Dr. Gawande pointed out that 234 million operations are done in the world each year—1 for every 25 people. About 7 million of these operations result in complications. About half of the complications are preventable.1 The surgical safety checklist is designed to reduce these preventable complications.

Dr. Gawande stated that before using a checklist, the eight pilot hospitals had a complication rate of 11%, with 64% of patients failing to get one or more of six safe surgical practices. After using the surgical safety checklist for the first 1,000 patients, the percentage of patients not getting one or more of six safe surgical practices dropped in half to 32%.

The Sign In consists of

  • verification of the operative documents with the patient,
  • checking that the site has been marked if indicated,
  • completion of an anesthesia safety check,
  • confirmation of pulse oximetry monitoring,
  • documentation of allergies,
  • assessment of airway, and
  • confirmation of the adequacy of intravenous access.

The Time Out consists of

  • introduction of the team members;
  • confirmation of the site;
  • review of critical steps by the surgeon, anesthesia professional, and nurse;
  • confirmation of antibiotic use; and
  • confirmation of images.

The Sign Out consists of

  • confirmation of the procedure,
  • confirmation of the counts,
  • confirmation of the specimen label,
  • mention of equipment problems, and
  • plan for patient recovery.

Each of the eight pilot hospitals recounted its experience. Many of the hospitals described an initial resistance, followed by a realization that the checklist not only identified missing elements, but also reinforced teamwork. Many said that each of the three parts of the checklist took less than one minute to complete. Almost every site modified the checklist slightly, while maintaining the prescribed elements. For instance, the Canadian site added prophylaxis for deep venous thrombosis to the checklist. Within months, the members of the operating teams felt the checklist was essential.

Dr. Gawande hoped that every surgeon and surgical team would try using the checklist just once. He was confident that they would want to use it again.

As director of the Pennsylvania Patient Safety Reporting System reviewing approximately 5,000 medical error reports each week and as a surgeon, I encourage all operating room committees in Pennsylvania to incorporate the “WHO Surgical Safety Checklist” into their workflow and track the impact. For more information about the “WHO Surgical Safety Checklist,” please go to the WHO Web site ( or contact me. For those who are interested, WHO has copies of the checklist and an implementation manual available at

John R. Clarke, MD
Editor, Pennsylvania Patient Safety Advisory
Clinical Director, PA-PSRS
Professor of Surgery, Drexel University


  1. 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 Jul 12;372(9633):139-44.
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