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Table of Contents
Year : 2022  |  Volume : 8  |  Issue : 1  |  Page : 38-42

World health organization surgical safety checklist of all OT cases

Department of General Surgery, Santosh Medical College and Hospital, Santosh Deemed to be University, Ghaziabad, Uttar Pradesh, India

Date of Submission16-Apr-2022
Date of Decision20-Apr-2022
Date of Acceptance25-Apr-2022
Date of Web Publication21-Jul-2022

Correspondence Address:
Shalabh Gupta
No. 14/22, Hare Krishna Marg, Block-14, Sector 10, Raj Nagar, Ghaziabad - 201 002, Uttar Pradesh
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/sujhs.sujhs_18_22

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Background: The available literature shows that approximately 75 million patients are experiencing postoperative complications that lead to about 2 million deaths every year. Thereby, there is an immense need to take care of all safety precautions for the surgery listed by the World Health Organization (WHO).
Aim and Objectives: The aim is (1) To study the impact of the implementation of a surgical safety checklist on patient safety. (2) To study the compliance of the surgical team to the implementation of a surgical safety checklist following an education program.
Materials and Methods: The present study is a prospective randomized controlled study conducted at Santosh Medical College and Hospital, Ghaziabad (Uttar Pradesh). The study was conducted from December 2019 to November 2020.
Results: More than half of the standards were above 50% implemented in the operation theaters. Of the standards of before skin incisions, above 50% of them were not implemented. However, of the implemented standards, >75% were followed. In addition, the standards of before any member of the team left the operating room, above 75% of them were appropriately implemented in our setup.
Conclusion: We conclude that the use of the WHO checklist prevents complications and reduces the inhospital length of stay, changes in morbidity, and potentially mortality as well across a wide range of patients undergoing simple or complex surgical procedures in hospitals within a well-developed and funded health-care system.

Keywords: OT cases, safety checklist, surgical, World Health Organization

How to cite this article:
Dugga IA, Jha MM, Khan N, Gupta S, Bhagat TS. World health organization surgical safety checklist of all OT cases. Santosh Univ J Health Sci 2022;8:38-42

How to cite this URL:
Dugga IA, Jha MM, Khan N, Gupta S, Bhagat TS. World health organization surgical safety checklist of all OT cases. Santosh Univ J Health Sci [serial online] 2022 [cited 2022 Aug 11];8:38-42. Available from: http://www.sujhs.org/text.asp?2022/8/1/38/351566

  Introduction Top

The positive effects of the use of surgical safety checklists, facilities have had difficulty implementing this tool. Some studies report that the checklist was seen as inconvenient, and its use required adjusting ingrained behavior patterns.[1]

Barriers to use include anxiety with unfamiliar processes, the hierarchy of staff, logistics and timing, duplication, the relevance of checklist, absence of consequences when the checklist was not completed, misuse of the checklist, and a lack of integration into existing hospital information systems.[2] Even when checklists were implemented, the use was frequently inconsistent in timing and location.[3] Studies on compliance with surgical safety checklists show use rates ranging from 12% to 100%.[4]

There is a dearth of research regarding the time-out process in rural operating rooms. One study examined the effects of the implementation of a checklist for the time-out on teamwork in a rural operating room.[2]

This study found that the use of a time-out protocol such as a checklist improved time-out and teamwork in the rural setting; however, there is little research on how rural facilities use these tools.[5] A second study that included the rural setting also found that the use of a surgical safety checklist improved patient outcomes; however, this study only included one rural hospital and aggregated the findings with the results from seven urban facilities.[6]

Almost all research on time-outs occurred in large, teaching facilities. Many of the interventions designed to improve the time-out process have been developed and tested in large, urban facilities and may or may not be applicable to the rural setting. Compliance with time-out recommendations may also be an issue as one study in an urban setting found that verifications of surgical site markings, patient positioning, radiographic imaging, and verification of the availability of the appropriate equipment and implants occurred in <30% of the surgical cases.[7],[8]

Aim and objectives

  1. To study the impact of the implementation of a surgical safety checklist on patient safety
  2. To study the compliance of the surgical team to the implementation of a surgical safety checklist following the education program.

  Materials and Methods Top

  • Place of study – Department of General Surgery, Santosh Medical College and Hospital, Ghaziabad
  • Duration of study – December 2019–November 2020
  • Study design – Prospective randomized controlled study
  • Sample size – 89.

Inclusion criteria

  1. All patients of all age groups of both sexes
  2. All operative procedures under genetic algorithm (GA)/simulated annealing (SA)
  3. Elective procedure.

Exclusion criteria

  1. Patients who refuse to be a part of the study
  2. Emergency operations.

  Observations and Results Top

Age-wise distribution of the patients under this current study is shown in [Figure 1]. It was found that the minimum age of at least 2 (2.25%) patients was below 10 years of old, and one patient was above the age of 71 years.
Figure 1: Age-wise distribution of all patients

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[Figure 2] shows the average age of the patients involved in this present study. The mean age of the male patients was found to be 35.43 ± 17.12, and females were 39.12 ± 13.15.
Figure 2: Age Distribution of all patients

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Male and female patients involved in this study are shown in [Figure 3]. It was found that 47 (53%) males and 42 (47%) females were involved in this current study. That male:female ratio was 1.12:1.0.
Figure 3: Gender Distribution of all patients

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Figure 4: Gender Distribution in Appendicitis

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Results observed from the diagnosis of the patients under the current study are shown in [Table 1]. The majority of the patients, i.e., 25 (28.09%) of the 89 were diagnosed for cholelithiasis, whereas right inguinal hernia in eight patients, acute appendicitis in 6 of the patients and 5 as Grade 2 hemorrhoids were identified. All others were found to be ≤3.
Table 1: Diagnostic results of the patients for various complications

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In the present study, it was identified that majority of the patients were diagnosed for cholelithiasis, i.e., 25 of the 89 patients where 22 of them were found to be females and 3 males. Among the females, it was also noted that the majority (12 of them) are between the age of 31 and 40 years.

Of 89 patients, 5 were diagnosed with Grade 2 hemorrhoids.[4] Three of them were males, among which 1 in each of the age groups of 21–30, 31–40, and 41–50 years. Two females were diagnosed with Grade 2 hemorrhoids, 1 each in the 31–40 and 51–60 years of age groups, respectively.

In the current study, 6 of 89 patients were diagnosed with acute appendicitis [Table 4]. Three of them were male, where 2 of them belonged to the age of <20 and one in the group of 21–30 years old. Furthermore, of 3 females diagnosed for acute appendicitis, 1 was under 20 years of age and 2 of them were between 21 and 30 years of age.
Table 2: Age and sex pattern of patients diagnosed with cholelithiasis

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Table 3: Age and sex patterns of the patients diagnosed with right inguinal hernia

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Table 4: Age and sex pattern of the patients diagnosed with acute appendicitis

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[Table 5] clearly depicts the details of the patients based on the different types of surgical procedures used for their treatment. From the table, it is clear that of the total 89 patients involved in our present study, 23 (25.84%) have undergone lap Chole under general anesthesia, followed by 8 (8.99%) patients have right mesh hernioplasty under SA, 7 (7.87%) of the patients with lap appendectomy under GA, and 5 (5.62%) of the patients were under the excision under SA and Minimal Invasive Procedure for Hemorrhoidectomy (MIPH) under SA, respectively.
Table 5: Number of patients under different types of surgery

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The different types of anesthesia used for the patients during their surgical procedures in our current study are clearly tabulated in [Table 6]. It was recorded that general anesthesia was used for 43 (48.31) patients in this study, whereas the sedative anesthesia was applied for 37 (41.57%) patients, only one (1.12%) patient was under local anesthesia. Of the total patients, 8 (8.99%) patients' anesthesia are not known.
Table 6: Number of patients with different types of anesthesia

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  Discussion Top

There are some significant disparities related to the perceptions of the surgeons and the other team members about indicating the barriers related to effective communication were observed.

In a clinical audit done in London, the performance of surgical safety checklist was 7.9% with 8.5% rate of early complications, but after training, the performance was 96.9% with 7.6% rate of early complications. Seventy-seven thought that the surgical safety checklist improved team communication. In an audit done at the UK, surgical checklist implementation was optimized, regardless of the setting, when used as a tool in multifaceted cultural and organizational programs to strengthen patients' safety. However, in this clinical perspective study, there were certain techniques standards that were not completely practiced in some procedures such as risk of bleeding documentation before induction of anesthesia, team members introducing each other, venous thromboembolism prophylaxis administration for the indicated patients, displaying essential images for the available ones before surgical incision. It may be due to this introducing surgical checklists are not as straightforward as it seems and requires leadership, flexibility, and teamwork in a different way to that which is currently practiced. The concept of using a checklist in surgical and anesthetic practice was believed that by routinely checking common safety issues and by better team communication and dynamics, perioperative morbidity and mortality could be improved. The magnitude of improvement demonstrated by the World Health Organization (WHO) pilot studies was surprising. These initial results have been confirmed by further detailed work demonstrating that surgical checklists, when properly implemented, can make a substantial difference to patient safety. Hence, according to the WHO and Federal Ministry of Health goals, this surgical safety checklist is the best tool for safe surgery and for better outcome of surgical patients and is momentous and minimizes surgical harms if practiced fully in the operating theaters.

Even though the checklist has been implemented to improve the patients' safety and patient care, the defendants still have the considerable amount of concern about the way it is perceived efficiently.[9] Therefore by these effective modifications, we can improve the quality of surgical procedures.

Surgical safety checklists characterize a comparatively simple and promising strategy to address the safety of patients those who are undergoing for surgery worldwide. Based on the literature search and to our understanding, no direct harms have been notified with the use of surgical safety checklist. However, there are possibilities in cooperated efficiency if the checklists are duplicated from the existing procedures or there may be issues in the execution of the checklist if the responsible nurses for performing the checklist are not familiar as well. Besides, it is also quite common that medical errors might occur at any aspect of medicine, including the surgical environment, special challenges to safeguarding patients' safety as well. Therefore, considering patients' safety as a priority during surgery, full attention of skilled individuals using well-functioning equipment under sufficient supervision under experienced personnel is highly recommended.

  Conclusion Top

This study showed that assumptions about the context and optimizing the checklist require careful evaluation and analysis so that they match the exact practice along with the local setups. It also demonstrates that changes in teamwork practices do not automatically follow checklist introduction, even where nontechnical items are included, but rather require explicit and interventional focus. Checklists are neither a “quick-fix” nor a tool that can be effectively implemented in isolation; in resource-constrained settings, they are especially unlikely to be free of costs and risks.[10],[11] Safety checklists are most likely to be effective and sustainable when implemented as part of broader, multifaceted programs addressing social, behavioral, logistical, and organizational issues[12],[13] where there is a strong institutional focus on patient safety, multidisciplinary leadership, monitoring systems in place, and consequences at all levels for noncompliance.

We conclude that the use of the WHO checklist prevents complications and reduces inhospital length of stay, changes in morbidity and potentially mortality as well across a wide range of patients undergoing simple or complex surgical procedures in hospitals within a well-developed and funded health-care system.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Panesar SS, Cleary K, Sheikh A, Donaldson L. The WHO checklist: A global tool to prevent errors in surgery. Patient Saf Surg 2009;3:9.  Back to cited text no. 1
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.  Back to cited text no. 2
NHS Errors Costing Billions a Year e Jeremy Hunt; 2014. Available from: http://www.bbc.co.uk/news/uk-29639383. [Last accessed on 2014 Oct 16].  Back to cited text no. 3
Finks JF, Osborne NH, Birkmeyer JD. Trends in hospital volume and operative mortality for high-risk surgery. N Engl J Med 2011;364:2128-37.  Back to cited text no. 4
Jencks SF, Williams MV, Coleman EA. Rehospitalizations among patients in the Medicare fee-for-service program. N Engl J Med 2009;360:1418-28.  Back to cited text no. 5
Pearse RM, Moreno RP, Bauer P, Pelosi P, Metnitz P, Spies C, et al. Mortality after surgery in Europe: A 7 day cohort study. Lancet 2012;380:1059-65.  Back to cited text no. 6
Ghaferi AA, Birkmeyer JD, Dimick JB. Variation in hospital mortality associated with inpatient surgery. N Engl J Med 2009;361:1368-75.  Back to cited text no. 7
Reames BN, Scally CP, Thumma JR, Dimick JB. Evaluation of the effectiveness of a surgical checklist in medicare patients. Med Care 2015;53:87-94.  Back to cited text no. 8
Bosk CL, Dixon-Woods M, Goeschel CA, Pronovost PJ. Reality check for checklists. Lancet 2009;374:444-5.  Back to cited text no. 9
Kotagal M, Lee P, Habiyakare C, Dusabe R, Kanama P, Epino HM, et al. Improving quality in resource poor settings: Observational study from rural Rwanda. BMJ 2009;339:b3488.  Back to cited text no. 10
Ider BE, Adams J, Morton A, Whitby M, Muugolog T, Lundeg G, et al. Using a checklist to identify barriers to compliance with evidence-based guidelines for central line management: A mixed methods study in Mongolia. Int J Infect Dis 2012;16:e551-7.  Back to cited text no. 11
Walker IA, Merry AF, Wilson IH, McHugh GA, O'Sullivan E, Thoms GM, et al. Global oximetry: An international anaesthesia quality improvement project. Anaesthesia 2009;64:1051-60.  Back to cited text no. 12
Weiser TG, Krummel TM. Surgical safety checklists in Ontario, Canada. N Engl J Med 2014;370:2349-50.  Back to cited text no. 13


  [Figure 1], [Figure 2], [Figure 3], [Figure 4]

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]


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