The World Health Organization Surgical Safety Checklist: Happy 10th Birthday!

Abstract

In 1935, a Boeing military aircraft crashed immediately after take-off because the crew forgot to release the flight control gust locks. In 2018, in this issue of Anesthesia & Analgesia, Igaga et al1 describe the use of the World Health Organization (WHO) Surgical Safety Checklist (SSC) at 5 referral hospitals in Uganda. There is a direct connection between these events. The accident with the B-17 Flying Fortress led to the realization that the aircraft was, as has been said, “too much airplane for one man to fly,” and subsequently to the introduction of checklists in aviation. It took a long time for the medical field to accept that the perioperative period also may be too complex to rely on memory, but a few visionaries (including Harvard surgeon Atul Gawande) did the research, and showed that use of a perioperative checklist could reduce complications (see below). In 2008, the WHO SSC was introduced—10 years ago. It is therefore an appropriate moment to consider the current status of the SSC around the world, of which the article by Igaga et al1 is a good example. In retrospect, it is surprising that it took so long because the complication rate worldwide is much higher after surgery than after flying an airplane (also, there is likely greater variability in patients and in the challenges faced routinely by surgical and anesthesia teams). Studies from high-income countries (HICs) show a perioperative death rate from inpatient surgery of 0.4%–0.8% and a rate of major complications of 3%–17%.2,3 With >300 million operations performed every year,4 this would translate to close to 10 million complications and >1 million deaths. The death rate related to anesthesia ranges from 1 in 50,000 to 1 in 200,000.5 Fifty percent of deaths are due to mistakes and considered avoidable.2 These numbers are optimistic, however, because complication rates in low-/middle-income countries (LMICs) are much higher, and perioperative death rates are reported from 0.1% to 1%.6,7 As in HICs, many complications are preventable: a report from Thailand suggests that 61% of incidents in the operating room happened because of inexperience, inadequate vigilance, lack of adequate preanesthetic evaluation, lack of adequate decision-making, emergency situations, lack of supervision, and communications issues.8 A study done in Tunisia considered 60% of complications preventable.9 It is this kind of data that resulted in a multidisciplinary group of experts proposing the 19-item WHO SSC.10 The checklist is executed orally with the whole perioperative team. It is in 3 parts: before administration of anesthesia, before incision, and before the patient leaves the operating room. It contains basic steps to ensure safe anesthesia, infection prevention by appropriate antibiotic prophylaxis, effective teamwork, and other essential practices in perioperative care. How does it perform? In a pivotal study, the WHO SSC was implemented in 8 countries, including 4 HICs and 4 LMICs.11 It was translated into local language where needed and modified for easy understanding at each institution. The local staff introduced the checklist to operating room personnel, using lectures, written materials, or direct guidance. Checklist implementation was associated with overall reductions in mortality from 1.5% to 0.8% and inpatient complications from 11% to 7%. In this study, only 1 HIC institution showed improvements with checklist implementation, and all other improvement occurred in the LMIC institutions. However, a subsequent study from a HIC (the Netherlands) showed an absolute risk reduction for perioperative mortality of 0.7% and for complications of 10.6%.12 Despite persisting concern about a Hawthorne effect in before–after cohort studies, these results were greeted with great enthusiasm and led over time to worldwide introduction of the WHO SSC. The checklist-associated safety improvement noted in LMIC, combined with the high perioperative complication rates in those countries, suggests particular usefulness in that setting. The checklist has been implemented in many LMICs and has been evaluated in hospitals in several countries. The experience at these sites demonstrates variable success in process measures, outcomes, and ability to reliably capture data.13,14 A survey study including the main referral hospitals in 5 East African countries (Uganda, Kenya, Tanzania, Burundi, and Rwanda) found that between February 2013 and March 2014, none of the anesthetists in Mulago (Uganda) or Centre Hospitalo-Universitaire de Kamenge (Burundi) used the checklist (citing unavailability), whereas Muhimbili (Tanzania), Kenyatta (Kenya), and Centre Hospitalier Universitaire de Kigali (Rwanda) used it in 65%, 19%, and 36% of cases, respectively.15 The article by Igaga et al1 in this issue of the Journal reports on WHO SSC implementation and outcomes in 5 referral hospitals in Uganda. Their findings largely match those listed above: a checklist compliance rate of 42%, with great variability among hospitals, yet (in analysis of secondary outcomes) no association between checklist compliance and mortality, adverse events, or length of hospitalization. It is critically important to separate problems with implementation of the SSC from any lack of inherent utility of the instrument in certain settings. The latter requires very large patient numbers to demonstrate. The study by Igaga et al1 exemplifies this issue. Their findings clearly show that checklist compliance, as determined by observers in the operating room, was low. However, with <900 patients, this study was not powered to determine outcomes (as acknowledged by the authors). The lack of association between checklist use and outcomes must therefore not be interpreted as indicating that the instrument is not effective; the study was simply not designed to investigate this. The main struggle in many settings has been to get people to see the SSC as more than a list of tick boxes that one is forced to check (and it is not clear in the study by Igaga et al1 to what degree clinicians were thoughtfully involved in the process of completing the list), and several investigators have studied optimal approaches to comprehensive introduction of the instrument.16,17 Unless regular and thoughtful use of the SSC is assured, with positive and active engagement of senior clinicians, the demonstrated outcome benefits will not be realized. Health care professionals need to understand the reasons behind its use; the “why” and “how” should therefore be communicated and emphasized. For example, implementing the checklist in LMICs allows identification of major deficiencies in capacity that make it impossible to meet the requirements of items on the list. An important initiative to address this is combining donation of pulse oximeters with distribution and training in use of the WHO SSC, as done by the LifeBox program.13 Taken together, these findings emphasize the need not only to make the checklist available but also to train the surgical team on the importance of using it, and to identify local surgeons and anesthesiologists to champion its implementation in LMIC. Ministries of Health can play a major role in this. It is hard to escape the impression that the 10-year history of the WHO SSC has been somewhat checkered, particularly in LMIC. Although cohort studies showed that proper implementation of checklists improves patient safety considerably, particularly in LMIC, implementation has not been straightforward and has not always been sustainable. Many reasons may be responsible: unsupportive leadership, lack of flexibility, workload, hesitancy to change existing practices, etc. Anesthesiologists are in a good position to encourage proper SSC use in the operating room because they are already familiar with the use of anesthetic machine checklists (although those also may not be used as they should). It is important to do so, for successful implementation of the SSC worldwide, in parallel with increased capacity to allow all its items to be positively and truthfully completed, has the potential for enormous impact on outcomes. And safety checklists are not limited to the operating room: the intensive care unit, the emergency department, and other units are likely to benefit from this simple, yet remarkably effective technology. Advocacy, training, and coaching should therefore be priorities, so that hopefully, in 2028, we can report worldwide, consistent use of the WHO SSC. DISCLOSURES Name: Paulin R. Banguti, MD. Contribution: This author critically reviewed all versions of the manuscript. Name: Jean Paul Mvukiyehe, MD. Contribution: This author helped write the initial draft of the manuscript. Name: Marcel E. Durieux, MD, PhD. Contribution: This author helped edit the subsequent drafts of the manuscript. This manuscript was handled by: Angela Enright, MB, FRCPC.