Implementation Of Safety Checklist Research Articles

Evaluating the uptake and effect of Surgical Safety Checklist implementation in a rural hospital, Neno District, Malawi

BackgroundThe WHO introduced the Surgical Safety Checklist (SSC) in 2008, which has been proven to enhance collaboration and patient safety before, during and after surgical procedures. However, the impact of...

CheckPOINT: a simple tool to measure Surgical Safety Checklist implementation fidelity

IntroductionThe WHO Surgical Safety Checklist (SSC) is a communication tool that improves teamwork and patient outcomes. SSC effectiveness is dependent on implementation fidelity. Administrative audits fail to capture most aspects...

Safety checklist implementation in invasive cardiology: a single center experience

Safety checklist implementation in invasive cardiology: a single center experience

Implementation of systematic safety checklists in a neurocritical care unit: a quality improvement study

Background and objectivesStructured and systematised checklists have been shown to prevent complications and improve patient care. We evaluated the implementation of systematic safety checklists in our neurocritical care unit (NCCU)...

Municipality-Level Checklist to Promote Parental Behaviors Related to Prevention of Unintentional Injury in Young Children: A Multilevel Analysis of National Data.

BackgroundUnintentional injury is a major cause of morbidity and mortality among young children in developed countries. In this national study, we examined the role of municipality-level safety checklist implementation for reducing risky child-safety-related parental behaviors.MethodsNationwide data were collected to evaluate the impact of the Healthy Parents and Children 21 initiative of the Japanese government. Questionnaires related to safety checklist implementation were administered to a random sample of municipal offices and to parents at the child’s routine 1.5-year health exam on parental behaviors related to child safety. Adjusting for municipality and individual-level variables, multilevel analysis was used to examine the relationship between municipality checklist implementation (4-month health exam) and six child-safety-related parental behaviors at the 1.5-year health exam.ResultsFamilies (n = 23,394) across 371 municipalities in Japan were included in this study; 5.6% of municipalities implemented a child safety intervention. Living in a municipality with a checklist intervention was associated with reduction in certain risk behaviors (not keeping tobacco/ashtray and candy out of the reach of infants, not using a car seat, not having a lock on bathing room door). However, after additionally taking into account municipality-level residual effects, only the “tobacco” behavior showed association with municipality of residence (Interval odds ratio, 0.25–0.94) and others were weak in the context of other potential municipality-level influences.ConclusionsA municipality-level intervention taking a checklist-based approach at the 4-month health exam in Japan appears to promote certain child safety behaviors in parents with children around 1.5 years of age.

The DIFFERENCE OF OBEDIENCE SURGICAL TEAM IN THE IMPLEMENTATION OF SURGICAL SAFETY BETWEEN ELECTIVE AND EMERGENCY SURGERY PATIENTS IN KARSA HUSADA HOSPITAL BATU

Patient safety with surgery becomes the main focus in medical action, as it involves invasive procedure. The surgical team’s obedience is very important to reduce the risk at the surgery procedure. At 2007, WHO has released a method for keep the patient safety in Surgical Safety Checklist (SSC) form, to reduce the patient’s mortality. The purpose from this research is to know the difference of surgical team’s obedience in implementation of surgical safety between elective and emergency surgical patient at Karsa Husada Hospital’s operating room. The research design that used is comparative design with cross-sectional approach, with the amount of sample is 22 person and used the purposive sampling according to the both inclusion and exclusion criteria. The method of collecting data implemented by non-participative observation to the surgical team that conducting the operation each 15 times to both the elective dan emergency surgery patient. The research instrument that used was SSC observation form and it was customized by hospital’s form. The tabulating data that used was analytic comparative technic with Chi Square test. The research’s result show the surgical team’s obedience in surgical safety checklist implementation at elective surgical patient is 80% was scored obey, meanwhile at emergency surgical patient is only 7% was scored obey, and the significance score is 0,000, that means there is a difference of surgical team’s obedience in the implementation of surgical safety between elective and emergency surgery patient. The recommendation given to the surgical team is the team is expected to carry out the surgical safety maximally and don’t missed some of the SSC’s point especially at the both of time out and sign out phase.
 Keywords: Obedience, surgical team, surgical safety, elective, emergency

Safety Checklist Implementation Did Not Reduce Central Venous Catheter Duration in Pediatric Cardiac ICU Patients.

Introduction:The Center for Disease Control recommends prompt removal of nonessential central venous catheters (CVCs) to reduce the risk for central line–associated bloodstream infections. Safety checklists have been trialed to reduce nonessential CVC days, but pediatric studies are lacking. Our specific aim was to detect >10% reduction in mean CVC duration after implementation of a safety checklist addressing CVCs in our unit.Methods:All patients admitted to the Congenital Cardiovascular Care Unit at New York University Langone Medical Center who had a CVC placed between January 1, 2012, and December 31, 2017, were included. We implemented a checklist addressing CVC use in our unit on June 7, 2013, and modified it on March 10, 2016. We analyzed quarterly mean CVC duration and postsurgical CVC duration over the study period using statistical process control charts.Results:We placed 778 CVCs for 7,947 CVC days during the study period. We noted special cause variation from Q4 2013 to Q2 2014 and a centerline shift in mean CVC duration from 8.91 to 11.10 days in Q1 2015. In a subgroup analysis of the 657 lines placed in surgical patients, there was a centerline shift in mean CVC duration from 6.48 to 8.86 days in Q4 2013.Conclusions:Our study demonstrated an unexpected increase in mean CVC duration after the implementation of a safety checklist designed to decrease nonessential CVC days. Additional studies are needed to identify the ideal method to detect and remove nonessential CVCs and reduce the risk of preventable harm.

Using the Knowledge to Action Framework to Describe a Nationwide Implementation of the WHO Surgical Safety Checklist in Cameroon

BACKGROUND:Surgical safety has advanced rapidly with evidence of improved patient outcomes through structural and process interventions. However, knowledge of how to apply these interventions successfully and sustainably at scale is often lacking. The 2019 Global Ministerial Patient Safety Summit called for a focus on implementation strategies to maintain momentum in patient safety improvements, especially in low- and middle-income settings. This study uses an implementation framework, knowledge to action, to examine a model of nationwide World Health Organization (WHO) Surgical Safety Checklist implementation in Cameroon. Cameroon is a lower-middle-income country, and based on data from high- and low-income countries, we hypothesized that more than 50% of participants would be using the checklist (penetration) in the correct manner (fidelity) 4 months postintervention.METHODS:A collaboration of 3 stakeholders (Ministry of Health, academic institution, and nongovernmental organization) used a prospective observational design. Based on knowledge to action, there were 3 phases to the study implementation: problem identification (lack of routine checklist use in Cameroonian hospitals), multifaceted implementation strategy (3-day multidisciplinary training course, coaching, facilitated leadership engagement, and support networks), and outcome evaluation 4 months postintervention. Validated implementation outcomes were assessed. Primary outcomes were checklist use (penetration) and fidelity; secondary outcomes were perioperative teams’ reactions, learning and behavior change; and tertiary outcomes were perioperative teams’ acceptability of the checklist.RESULTS:Three hundred and fifty-one operating room staff members from 25 hospitals received training. Median time to evaluation was 4.5 months (interquartile range [IQR]: 4.5–5.5, range 3–7); checklist use (penetration) increased from 20% (95% confidence interval [CI], 16–25) to 56% (95% CI, 49–63); fidelity for adherence to 6 basic safety processes was high: verification of patient identification was 91% (95% CI, 87–95); risk assessment for difficult intubation was 79% (95% CI, 73–85): risk assessment for blood loss was 88% (95% CI, 83–93) use of pulse oximetry was 93% (95% CI, 90–97); antibiotic administration was 95% (95% CI, 91–98); surgical counting was 89% (95% CI, 84–93); and fidelity for nontechnical skills measured by the WHO Behaviorally Anchored Rating Scale was 4.5 of 7 (95% CI, 3.5–5.4). Median scores for all secondary outcomes were 10/10, and 7 acceptability measures were consistently more than 70%.CONCLUSIONS:This study shows that a multifaceted implementation strategy is associated with successful checklist implementation in a lower-middle-income country such as Cameroon, and suggests that a theoretical framework can be used to practically drive nationwide scale-up of checklist use.

A Team-Based Approach to Introduce and Sustain the Use of the WHO Surgical Safety Checklist in Tanzania.

Millions of patients worldwide suffer disability and death due to complications related to surgery. Many of these complications can be reduced by the use of the World Health Organization (WHO) Surgical Safety Checklist (SSC), a simple tool that can enhance teamwork and communication and improve patient safety. Despite the evidence on benefits of its use, introducing and sustaining the use of the checklist are challenging. We present a team-based approach employed in a low-resource setting in Tanzania, which resulted in high checklist utilization and compliance rates. We reviewed reported data from facility registers supplemented by direct observation data by mentors to evaluate the use of the WHO SSC across 40 health facilities in two regions of Tanzania between January and December 2018. We analyzed the self-reported monthly data on total number of major surgeries performed and proportion of surgeries where the checklist was used. We also analyzed the use of the SSC during direct observation by external mentors and completion rates of the SSC in a random selection of patient files during two mentorship visits between June and December 2018. During the review period, the average self-reported checklist utilization rate was 79.3% (11,564 out of 14,580 major surgeries). SSC utilization increased from 0% at baseline in January 2018 to 98% in December 2018. The proportion of checklists that were completely and correctly filled out increased between the two mentor visits from 82.1 to 92.8%, but the gain was significantly greater at health centers than at hospitals (p < 0.05). Health centers (which had one or two surgical teams) self-reported a higher checklist utilization rate than hospitals (which had multiple surgical teams), i.e., 99.4% vs 68.8% (p < 0.05). Our findings suggest that Surgical Safety Checklist implementation is feasible even in lower-resource settings. The self-reported SSC utilization rate is higher than reported in other similar settings. We attribute this finding to the team-based approach employed and the ongoing regular mentorship. We recommend use of this approach to scale-up checklist use in other regions in the country as recommended in the Ministry of Health of Tanzania's National Surgical, Obstetric, and Anesthesia Plan (NSOAP).

Review of “Causal Analysis of World Health Organization's Surgical Safety Checklist Implementation Quality and Impact on Care Processes and Patient Outcomes: Secondary Analysis From a Large Stepped Wedge Cluster Randomized Controlled Trial in Norway” by Haugen AS in Ann Surg 269:283–290, 2017

Review of “Causal Analysis of World Health Organization's Surgical Safety Checklist Implementation Quality and Impact on Care Processes and Patient Outcomes: Secondary Analysis From a Large Stepped Wedge Cluster Randomized Controlled Trial in Norway” by Haugen AS in Ann Surg 269:283–290, 2017

Role and impact of WHO Surgical safety checklist implementation on patient safety, in a tertiary level health care center

Background: With over more than 200 million operations performed per year worldwide, there seems to be an urgent need for a checklist to ensure an errorless surgical procedure. WHO surgical safety checklist(SSC) is one, which can help in minimising intraoperative and post-operative errors. In addition, it can also serve as a tool to encourage teamwork and communication among the hospital staff members. Methods: This 1 yearlong study was conducted in 2 parts, in the first held pre checklist implementation phase, complications and mortalities were recorded retrospectively and compared with post checklist implementation phase data. Total of 244 patients participated in the first phase and 236 patients were enrolled in the post checklist implementation phase. Compliance and compatibility with the checklist was tested by a questionnaire given to staff members. Results: Marked reduction in both intraoperative and post-operative complications was documented after checklist implementation. Intraoperative complications went down from 6.14% to 2.12% and post-operative from 6.56% to 3.38%. Similarly, intraoperative mortality rate scrolled down from 3.87% to 0.85% after checklist implementation. Regarding the compliance of the study, 95.3% of our hospital staff was in favour of introducing the WHO SSC as a routine practice in our hospital. Conclusion: WHO SSC is the need of the hour in order to reduce the intraoperative and post-operative complications. Incorporating WHO SSC in health care setup will not only result in improved health care quality but will surely reduce the cost burden in health sector.

Surgical safety checklist implementation and its impact on patient safety

Background: Surgery has become an integral part of global health care, with an estimated 234 million operations performed yearly. Surgical complications are common and often preventable. Although surgical and anesthetic caregivers seek to deliver optimal quality in peri-operative service, surgery still carries considerable risk for the patient. WHO surgical safety checklist outlines essential standards of surgical care and has been shown to reduce complications and death associated with surgery.Methods: Pre-intervention and post-intervention study. The effect on patient outcomes and documentation of WHO surgical safety checklist was examined. After an education programme, the checklist implementation and patient safety outcome indicators were studied.Results: Checklist compliance increased over time. The median number of items documented was 16. After implementation of the checklist, mortality decreased from 3.13% to 2.85%. Most causes of death did not significantly differ between the implementation periods, except for multiorgan failure and major bleeding. Adjustment of the association between implementation period and outcome for all variables revealed a decreased mortality after checklist implementation.Conclusions: Implementation of the checklist showed improved outcomes. Use of the WHO surgical safety checklist in urgent operations is feasible and should be considered. Implementation proved neither costly nor lengthy. Further research is needed to confirm these findings and reveal additional factors supportive of checklist implementation.

HUBUNGAN PELAKSANAAN SURGICAL SAFETY CHECKLIST DAN KEJADIAN INFEKSI POST OPERASI MAYOR

Background: wound postoperative infection (ILO) are infections caused by pathogenic microorganisms that contaminate the wound area during surgery or after surgery. The data from survey by World Health Organization (WHO) found that about ILO cuased infection as 5% - 34% of total nosocomial infections. The data from Centers for Disease Control and Prevention cited that annually there was 500,000 surgical site infections (SSI) and that caused 3% surgical mortality, prolonged length of stay in hospital, and increased medical costs. Objective: to know the correlation of Surgical Safety Checlist Implementation and post operative infection. Research method: the method was quantitative method with cohort analytic survey design. The population were all patients with major surgery at Public Hospital of Tugurejo Semarang periode December 2016 - January 2017 as many as 99 patients. &#x0D; Result:the result of this study were major surgery mostly have implementation of surgical safety checklist either 81 respondent (81,8%) and have no infection incidence were 84 responden (84,8%). There was no significant correlation between surgical safety checklist implementation and postoperative infection.

Effects on Clinical Outcomes of a 5-Year Surgical Safety Checklist Implementation Experience: A Large-scale Population-Based Difference-in-Differences Study.

The adoption of a surgical checklist is strongly recommended worldwide as an effective practice to improve patient safety; however, several studies have reported mixed results and a number of issues are still unresolved. The main objective of this study was to explore the impact of the first 5-year period of a surgical checklist-based intervention in a large regional health care system in Italy (4 500 000 inhabitants). We conducted a retrospective longitudinal study on 1 166 424 patients who underwent surgery in 48 public hospitals between 2006 and 2014. The adherence to the checklist was measured between 2011 and 2013 through a computerized database. The effects of the intervention were explored through multivariable logistic regression and difference-in-differences (DID) approaches, based on current administrative data sources. In-hospital and 30-days mortality, 30-days readmissions and length-of-stay (LOS) ⩾8 days were the observed outcomes. Adherence to the checklist showed marked variations across hospitals (0%-93.3%). A pre/post analysis detected statistically significant differences between surgical interventions performed in hospitals with higher adherence to the checklist (⩾75% of the surgeries) and those performed in other hospitals, as for the 30-days readmissions rate (odds ratio [OR]: 0.96; 95% confidence interval [CI]: 0.94-0.98) and LOS ⩾ 8 days rate (OR: 0.88; 95% CI: 0.87-0.89). These findings were confirmed after risk adjustment and DID analysis. No association was observed with mortality outcomes. On the whole, our study attained mixed results. Although a protective effect of the surgical checklist use could not be proved over the first 5 years of this regional implementation experience, our research offers some methodological insights for practical use in the evaluation process of large-scale implementation projects.

Satisfaction and Barriers of Surgical Safety Checklist Implementation in a Nonmandatory Adoption Resource-Limited Country.

A surgical safety checklist has been a globally implemented and mandated adoption in several countries. However, its use is not mandatory in Thailand. This study aimed to evaluate the perceptions of surgical personnel on surgical complications and safety and to examine the satisfaction and barriers of surgical safety checklist implementation. A survey study was performed between November 2013 and February 2015 in 61 Thai hospitals. A questionnaire capturing demographics, perceptions related to surgical complications and safety, and the satisfaction and barriers of surgical safety checklist implementation was distributed to surgical personnel. A total of 2024 surgical personnel were recruited. Nearly all of them reported experience or knowledge of an adverse surgical event (99.6%). Most thought that it could be preventable (98.2%) and quality care improvement could help reduce the occurrence of adverse events (97.7%). Overall, respondents reported a high level of satisfaction with the checklist (mean [SD] = 3.79 [0.71]). The three areas of highest satisfaction were benefit to the patient (mean [SD] = 4.11 [0.69]), benefit to the organization (mean [SD] = 4.05 [0.68]), and reduction in adverse events (mean [SD] = 4.02 [0.69]). Overall, the barrier for implementation of the checklist was rated as moderate (mean [SD] = 2.52 [0.99]). However, the means of barriers in each period, sign in, time out, and sign out, were rated as low (means [SD] = 2.41 [1.07], 2.50 [1.03], and 2.34 [1.01], respectively). The data document that the satisfaction with the checklist are fairly high. However, some barriers were identified. Efforts to increase understanding through more rigorous policy enforcement and strategic support may lead to improving the checklist implementation.

Causal Analysis of World Health Organization's Surgical Safety Checklist Implementation Quality and Impact on Care Processes and Patient Outcomes: Secondary Analysis From a Large Stepped Wedge Cluster Randomized Controlled Trial in Norway.

We hypothesize that high-quality implementation of the World Health Organization's Surgical Safety Checklist (SSC) will lead to improved care processes and subsequently reduction of peri- and postoperative complications. Implementation of the SSC was associated with robust reduction in morbidity and length of in-hospital stay in a stepped wedge cluster randomized controlled trial conducted in 2 Norwegian hospitals. Further investigation of precisely how the SSC improves care processes and subsequently patient outcomes is needed to understand the causal mechanisms of improvement. Care process metrics are reported from one of our earlier trial hospitals. Primary outcomes were in-hospital complications and care process metrics, e.g., patient warming and antibiotics. Secondary outcome was quality of SSC implementation. Analyses include Pearson's exact χ test and binary logistic regression. A total of 3702 procedures (1398 control vs. 2304 intervention procedures) were analyzed. High-quality SSC implementation (all 3 checklist parts) improved processes and outcomes of care. Use of forced air warming blankets increased from 35.3% to 42.4% (P < 0.001). Antibiotic administration postincision decreased from 12.5% to 9.8%, antibiotic administration preincision increased from 54.5% to 63.1%, and nonadministration of antibiotics decreased from 33.0% to 27.1%. Surgical infections decreased from 7.4% (104/1398) to 3.6% (P < 0.001). Adjusted SSC effect on surgical infections resulted in an odds ratio (OR) of 0.52 (95% confidence interval (CI): 0.38-0.72) for intervention procedures, 0.54 (95% CI: 0.37-0.79) for antibiotics provided before incision, and 0.24 (95% CI: 0.11-0.52) when using forced air warming blankets. Blood transfusion costs were reduced by 40% with the use of the SSC. When implemented well, the SSC improved operating room care processes; subsequently, high-quality SSC implementation and improved care processes led to better patient outcomes.

World Health Organization (WHO) surgical safety checklist implementation and its impact on perioperative morbidity and mortality in an academic medical center in Chile.

Health care organizations are unsafe. Numerous centers have incorporated the WHO Surgical Safety Checklist in their processes with good results; however, only limited information is available about its effectiveness in Latin America. We aimed to evaluate the impact of the checklist implementation on the in-hospital morbidity and mortality rate in a tertiary health care center. After Institutional review board approval, and using data from our hospital administrative records, we conducted a retrospective analysis of all surgical encounters (n = 70,639) over the period from January 2005 to December 2012. Propensity scoring (PS) methods (matching and inverse weighting) were used to compare the pre and postintervention period, after controlling for selection bias. After PS matching (n = 29,250 matched pairs), the in-hospital mortality rate was 0.82% [95% confidence interval (CI), 0.73–0.92] before and 0.65% (95% CI, 0.57–0.74) after checklist implementation [odds ratio (OR) 0.73; 95% CI, 0.61–0.89]. The median length of stay was 3 days [interquartile range (IQR), 1–5] and 2 days (IQR, 1–4) for the pre and postchecklist period, respectively (P < 0.01).This is the first Latin American study reporting a decrease in mortality after the implementation of the WHO Surgical Checklist in adult surgical patients. This is a strong and simple tool to make health care safer, especially in developing countries.

Avoidance of serious medical errors in refractive surgery using a custom preoperative checklist

To implement and measure the effect of a surgical safety checklist on the prevention of serious medical errors (never-events). Boston Eye Group, Boston, Massachusetts, USA. Retrospective cohort study. A safety checklist incorporating 28 sources of error was designed and implemented in December 2011 at the Boston Eye Group's refractive surgical center. Consecutive patients who had primary or enhancement laser vision correction (LVC) between July 2009 and February 2014 were included in this study. Before that date, a general checklist fashioned around the World Health Organization time-out procedure was used. The latter subjects were recruited as controls. The perioperative characteristics of both groups were retrospectively compared. The study comprised 2951 consecutive patients who had primary or enhancement LVC between July 2009 and February 2014; of these, 1417 patients (2744 eyes) had LVC after the implementation of a presurgical safety checklist. The general checklist fashioned around the World Health Organization time-out procedure was used for 1534 patients (2969 eyes). Both groups were comparable in patient age. The most common surgical procedures were laser in situ keratomileusis (78%) and laser-assisted subepithelial keratectomy with mitomycin-C (16%). Although there were 2 (0.07%) serious errors in the prechecklist cohort, none occurred following implementation of the safety checklist protocol (P = .23). The medical errors involved wrong refractive aim in 1 patient and wrong person-wrong procedure-wrong aim in another. Multiple potential sources of error exist in refractive surgery. The broad-scale implementation of a detailed presurgical safety checklist was helpful in minimizing and preventing serious errors (never-events) during LVC. Drs. Shapiro and Urman are members of the Institute for Safety in Office-Based Surgery, a nonprofit organization whose aims are to implement safety checklists for office-based surgery. No author has a financial or proprietary interest in any material or method mentioned.

Implementation of safety checklists in surgery: a realist synthesis of evidence.

AimThe aim of this review is to present a realist synthesis of the evidence of implementation interventions to improve adherence to the use of safety checklists in surgery.BackgroundSurgical safety checklists have been shown to improve teamwork and patient safety in the operating room. Yet, despite the benefits associated with their use, universal implementation of and compliance with these checklists has been inconsistent.Data sourcesAn overview of the literature from 2008 is examined in relation to checklist implementation, compliance, and sustainability.Review methodsPawson’s and Rycroft-Malone’s realist synthesis methodology was used to explain the interaction between context, mechanism, and outcome. This approach incorporated the following: defining the scope of the review, searching and appraising the evidence, extracting and synthesising the findings, and disseminating, implementing, and evaluating the evidence. We identified two theories a priori that explained contextual nuances associated with implementation and evaluation of checklists in surgery: the Normalisation Process Theory and Responsive Regulation Theory.ResultsWe identified four a priori propositions: (1) Checklist protocols that are prospectively tailored to the context are more likely to be used and sustained in practice, (2) Fidelity and sustainability is increased when checklist protocols can be seamlessly integrated into daily professional practice, (3) Routine embedding of checklist protocols in practice is influenced by factors that promote or inhibit clinicians’ participation, and (4) Regulation reinforcement mechanisms that are more contextually responsive should lead to greater compliance in using checklist protocols. The final explanatory model suggests that the sustained use of surgical checklists is discipline-specific and is more likely to occur when medical staff are actively engaged and leading the process of implementation. Involving clinicians in tailoring the checklist to better fit their context of practice and giving them the opportunity to reflect and evaluate the implementation intervention enables greater participation and ownership of the process.ConclusionsA major limitation in the surgical checklist literature is the lack of robust descriptions of intervention methods and implementation strategies. Despite this, two consequential findings have emerged through this realist synthesis: First, the sustained use of surgical checklists is discipline-specific and is more successful when physicians are actively engaged and leading implementation. Second, involving clinicians in tailoring the checklist to their context and encouraging them to reflect on and evaluate the implementation process enables greater participation and ownership.Electronic supplementary materialThe online version of this article (doi:10.1186/s13012-015-0319-9) contains supplementary material, which is available to authorized users.

Measuring Variation in Use of the WHO Surgical Safety Checklist in the Operating Room: A Multicenter Prospective Cross-Sectional Study

Full implementation of safety checklists in surgery has been linked to improved outcomes and team effectiveness; however, reliable and standardized tools for assessing the quality of their use, which is likely to moderate their impact, are required. This was a multicenter prospective study. A standardized observational instrument, the "Checklist Usability Tool" (CUT), was developed to record precise characteristics relating to the use of the WHO's surgical safety checklist (SSC) at "time-out" and "sign-out" in a representative sample of 5 English hospitals. The CUT was used in real-time by trained assessors across general surgery, urology, and orthopaedic cases, including elective and emergency procedures. We conducted 565 and 309 observations of the time-out and sign-out, respectively. On average, two-thirds of the items were checked, team members were absent in more than 40% of cases, and they failed to pause or focus on the checks in more than 70% of cases. Information sharing could be improved across the entire operating room (OR) team. Sign-out was not completed in 39% of cases, largely due to uncertainty about when to conduct it. Large variation in checklist use existed between hospitals, but not between surgical specialties or between elective and emergency procedures. Surgical safety checklist performance was better when surgeons led and when all team members were present and paused. We found large variation in WHO checklist use in a representative sample of English ORs. Measures sensitive to checklist practice quality, like CUT, will help identify areas for improvement in implementation and enable provision of comprehensive feedback to OR teams.