WHO Surgical Safety Checklist

The World Health Organization (WHO) published the WHO Surgical Safety Checklist and Implementation Manual in 2008[1] in order to increase the safety of patients undergoing surgery. An independent international study at 357 hospitals located in 58 countries has demonstrated that the use of a surgical safety checklist has been associated with a 38% lower odds of 30-day death after emergency abdominal surgery compared with the same operations performed at hospitals that didn't have a checklist.[2] A subsequent analysis with additional pooled global data from 76 countries showed that checklist use was associated with a significantly lower perioperative mortality rate in emergency laparotomy, with checklist use associated with a lower 30‐day perioperative mortality (OR 0·60, 0·50 to 0·73; P < 0·001) in multivariable models.[3] Checklist use was also significantly more common in countries with a high Human Development Index (HDI) than low HDI, yet the greatest absolute benefit was seen for emergency surgery in low‐ and middle‐HDI countries.

Overview

As the worldwide incidences of traumatic injuries, cancers and cardiovascular disease continue to rise, the impact of surgical intervention on public health systems continues to grow. The WHO has undertaken a number of global and regional initiatives to address surgical safety. The Global Initiative for Emergency and Essential Surgical Care[4] and the Guidelines for Essential Trauma Care[5] focussed on access and quality. The Second Global Patient Safety Challenge: Safe Surgery Saves Lives[6] addresses the safety of surgical care. The World Alliance for Patient Safety[7] initiated work on the Challenge in January 2007.

The checklist essentially identifies three distinct phases of an operation, each corresponding to a specific period in the normal flow of work: Before the induction of anaesthesia, before the incision of the skin, and before the patient leaves the operating facility. In each phase, a 'checklist coordinator' must confirm that the surgical team has completed the listed tasks before it proceeds with the procedure.

The intention of such a checklist is to systematically and efficiently ensure that all conditions are optimum for patient safety, and that all staff are identifiable and accountable, and errors in patient identity, site and type of procedure are avoided completely. By following a few critical steps, health care professionals can minimize the most common and avoidable risks endangering the lives and well-being of surgical patients.

It is important to increase awareness of this safety initiative.[8]

Before induction of anaesthesia

Before the patient undergoes anaesthesia, the patient must confirm his/her identity, the site of operation, what procedure is to be carried out and that he/she has consented for the procedure. The site of operation must be marked if applicable. Then the presence or absence of allergies must be checked, the amount of expected blood loss discussed, and an anaesthetic safety check must be completed.

Time Out

Before the surgical procedure begins (i.e. before the first incision), the entire team must take a 'time out' (stop and pause). At this stage, all people in the room must introduce themselves by name and role. The surgeon and anaesthetist must then confirm the name of the patient and the procedure taking place, and any anticipated critical events. These clinicians also discuss the need for antibiotics and imaging.

Sign Out

Before the patient leaves the operating room there is a further check, usually conducted by the nursing staff. The instrument, sponge and needle counts are checked, equipment is checked and specimens are checked as appropriately labelled. The surgeon, anaesthetist and nursing staff then must discuss any key concerns for recovery management of the patient.

I AM FOR SAFETY Surgical Checklist

In 2009, Yisrael Mordecai Safeek authored and published I AM FOR SAFETY safe surgery checklist in Physician Executive Journal based upon his experience as an anesthesiologist overseeing operating rooms in several states. The checklist is a modified version of the World Health Organization surgical safety checklist and includes safety checks required by the American Society of Anesthesiologists (ASA) and Joint Commission. It utilizes the easy-to-remember mnemonic I AM FOR SAFETY that documents the sequence of patient safety exercises that caregivers should employ.[9]

The easy-to-remember I AM FOR SAFETY checklist incorporated key patient safety exercises that should be performed during distinctly critical and vulnerable peri-operative time periods for surgical patients:

Sign in

From the moment that the patient checks until they are wheeled into the operative suite, the following safety checks are verified: Joint Commission two identifiers, medication allergy and reconciliation, site markings requirements, Anesthesiology fasting, oxygen, and airway status, transfusion and fluid requirements, and equipment availability before taking the patient into the operative suite.

Time out

Upon entering the operative suite the following quality and patient safety tasks are performed: Medicare Core Measure SCIP 1a, and Joint Commission Universal Protocol before surgical incision.

Sign out

Before closure of the operative wound, the following tasks should be completed: Yield of final instrument/supply count and specimen tally.

References
  1. "WHO | WHO surgical safety checklist and implementation manual". Who.int. 2010-12-08. Retrieved 2015-04-23.
  2. GlobalSurg Collaborative (2016). "Mortality of emergency abdominal surgery in high-, middle- and low-income countries". British Journal of Surgery. 103 (8): 971–988. doi:10.1002/bjs.10151. PMID 27145169.
  3. GlobalSurg Collaborative (2019). "Pooled analysis of WHO Surgical Safety Checklist use and mortality after emergency laparotomy" (PDF). British Journal of Surgery. 106 (2): 103–112. doi:10.1002/bjs.11051. PMC 6492154. PMID 30620059.
  4. "WHO | WHO Global Initiative for Emergency and Essential Surgical Care". Who.int. Retrieved 2015-04-23.
  5. "WHO | Essential trauma care project". Who.int. Retrieved 2015-04-23.
  6. "WHO | Safe Surgery". Who.int. Retrieved 2015-04-23.
  7. "WHO | World Alliance for Patient Safety". Who.int. 2004-10-27. Retrieved 2015-04-23.
  8. Sivathasan N, Rakowski KR, Robertson BF, Vijayarajan L (2010-11-26). "The World Health Organization's 'Surgical Safety Checklist': should evidence-based initiatives be enforced in hospital policy?". JRSM Short Rep. 1 (5): 40. doi:10.1258/shorts.2010.010007. PMC 2984370. PMID 21103132.CS1 maint: multiple names: authors list (link)
  9. Safeek, Yisrael. "I AM FOR SAFETY checklist". Healthcare Financial Management. Retrieved 2010-08-10.
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