Safe Surgery Saves Lives FAQ
Welcome! We are pleased to see that you are interested in our efforts to improve
global surgical safety. The first part of this document is designed to answer some general
overview questions you may have about the Checklist and the Safe Surgery Saves Lives
initiative. Once you have read these – or if you’re already interested in using the Checklist at
your institution – we invite you to read the second section of this document, which addresses
a number of questions frequently asked by those individuals interested in implementing the
Checklist where they are.
Background FAQ
1. Q: Why is the Checklist important?
A: 234 million major operations are performed annually across the world. This
translates to roughly one operation per every 25 people and indicates that the safety of
care is of significant public health importance. (For more on this statistic and its
implications, see our article in the Lancet:
www.who.int/patientsafety/safesurgery/knowledge_base/publications/en/index.html)
Moreover, given previously estimated rates of major complications and death following
inpatient surgery, we have postulated that – even using conservative estimates – 7 million
patients suffer complications following surgery, half of which are likely to be
preventable.
2. Q: What is the Checklist and how was the Checklist developed?
A: The WHO Safe Surgery Saves Lives Checklist was created by an international group
of experts gathered by the WHO with the goal of improving the safety of patients
undergoing surgical procedures around the globe. Input from anesthesiologists, operating
theatre nurses, surgeons, patients and other professionals was used in the development of
this tool. Both small and large scale clinical testing of the checklist has been performed
culminating in a multi-site pilot study with results published in the New England Journal
of Medicine in January 2009: http://content.nejm.org/cgi/content/full/NEJMsa0810119.
In sites that ranged from small district hospitals to large medical centers in diverse
geographical settings, the use of a 19-item checklist was demonstrated to reduce the
complications and mortality associated with a variety of surgical procedures by greater
than 30 percent. The checklist has been designed to be simple to use and applicable in
many settings. It is currently in active use in operating rooms around the world.
3. Q: What does the Checklist involve? How will it impact surgical practices?
A: The Checklist involves the coordination of the operating team – the surgeons,
anesthesia providers, and nurses – to discuss key safety checks prior to specific phases of
perioperative care: a “Sign In” prior to induction of anesthesia, a “Time Out” prior to skin
incision, and a “Sign Out” before the team leaves the operating room. Many of the
checks are already routine in some institutions, but surprisingly, few operating teams
accomplish them all consistently, even in the most advanced settings. In our pilot study,
we were able to show that use of the checklist increases adherence to safety standards and
reduces the rate of complications and mortality associated with surgical care.

4. Q: Don't hospitals already use Checklists?
A: Many hospitals do already have checks in place, but their consistent use is
dismayingly variable. Many developed settings perform a “Time Out” where the team
confirms the patient identity, procedure, and site of operation. Teams are using this time
to perform and expand briefing, but this has never been elaborated to the extent that the
Safe Surgery Saves Lives project has done.
5. Q: How do you know the Checklist works?
A: Between October 2007 and September 2008, we studied the effects of the checklist in
eight hospitals in eight cities (Toronto, Canada; New Delhi, India; Amman, Jordan;
Auckland, New Zealand; Manila, Philippines; Ifakara, Tanzania; London, England; and
Seattle, WA) representing a variety of economic circumstances and diverse populations
of patients. We prospectively collected data on clinical processes and outcomes from
3733 patients before and 3955 patients after the checklist was implemented. The results
of the study were published in the New England Journal of Medicine on January 29, 2009
and demonstrated dramatic improvements in both processes and outcomes (full text
available here: http://content.nejm.org/cgi/content/full/NEJMsa0810119). Indeed, use of
the checklist reduced the rate of deaths and complications by more than one third across
all 8 pilot hospitals. The rate of major inpatient complications dropped from 11% to 7%,
and the inpatient death rate following major operations fell from 1.5% to 0.8% after
implementation of the checklist. Moreover, the effect was of similar magnitude in both
high and low/middle income country sites. Even our site in rural Tanzania was able to
implement the checklist and see substantial improvements in outcomes, all at essentially
no cost to the system.
6. Q: What has been the response to the Checklist?
A: To date, more than 300 professional societies, health organizations, ministries, and
NGOs have endorsed the concept of the Safe Surgery Saves Lives Program. The task of
the program now is to build on this momentum and the information we gathered during
the pilot study to promote the widespread use, implementation, and dissemination of the
Checklist as a safety practice in every operation. Participating hospitals are encouraged
to register with the WHO
(http://www.who.int/patientsafety/safesurgery/hospital_form/en/index.html), and
dissemination progress can be tracked through our interactive online map: http://cga-
4.hmdc.harvard.edu:8080/Hospital/gmap1.htm
7. Q: Does the Checklist apply to all settings? How does it impact developed and
developing regions differently?
A: The most developed countries tend to have well established and codified guidelines
for the process of care during the perioperative period, although these are often
inconstantly applied. Other settings may lack clear guidelines and policies for directing
the perioperative process. The guidelines and Checklist can help countries and facilities
evaluate their own processes of care and improve surgical safety. Moreover, even in the
developed world, there is variability in adhering to basic safety practices.

Implementation FAQ
1. Q: My hospital is quite large with many operating rooms. How can I implement a
checklist in this environment?
A: The key to successful implementation is to start small. Start with a single operating
room on one day and see how it works. This will guide you to strategies for altering the
checklist to fit your needs, as well as identify potential barriers to adaptation.
2. Q: We already do these things. Why should we use a checklist?
A: While most or all of the items on the checklist may already be done at your hospital,
we have found that in most hospitals there are opportunities for improvement in
consistency. The checklist helps ensure that important safety steps are followed for each
and every operation.
3. Q: Our surgical teams don’t want to use the WHO Surgical Safety Checklist unless they
can change a few of the elements. Is it okay to make changes to the Checklist?
A: Yes, the checklist was not intended to be comprehensive, and we encourage
modifications for local use. We understand that the Checklist, while intended to be
universally applicable, is not always a perfect fit for all institutions. Modifications can be
made to include items that are deemed essential. However, please avoid making the
checklist too comprehensive. The more items added to it, the more difficult it will be to
successfully implement. Please refer to the Starter Kit for Implementing the Surgical
Safety Checklist and the Checklist Adaptation Guide for recommendations on adapting
the Checklist.
4. Q: My team often stays together for the whole day. Must we introduce ourselves before
every surgery?
A: The most critical time for introductions is at the beginning of an operative day. There
is no need to repeat introductions if they have already been made. However, if new
members join a room, they should introduce themselves as should every member of the
team present. Even if everyone knows each other, introductions are important as they
serve to reinforce team communication (and can help avoid embarrassment at having to
ask someone’s name with whom one has been working for a prolonged period of time!).
5. Q: Who should be in charge of running the checklist?
A: Although every member of the operating team – surgeons, anesthetists, nurses,
technicians, and other operating room personnel – is involved in its execution, a single
person should be responsible for leading the discussion of all components of the checklist
and is essential for its success. This will often be a circulating nurse, but it can be any
clinician or healthcare professional participating in the operation. This individual can
and should prevent the team from progressing to the next phase of the operation until
each step is satisfactorily addressed.

6. Q: Should we memorize the checklist?
A: No. Checklists are created to avoid the pitfalls of memorization and omissions that
occur when standardized processes are not clearly written and defined. The goal of the
Checklist is to help ensure that teams consistently follow a few critical safety steps and
thereby minimize the most common avoidable risks endangering the lives and well-being
of surgical patients.
7. Q: Do we need to actually check the boxes on the checklist?
A: No. The checklist was not designed as an audit tool; however, an institution can use
it as such if this is likely to improve the safety of surgical care. In addition to a piece of
paper, the checklist can be converted into a poster, incorporated into electronic records,
or laminated for reuse.
8. Q: What’s in it for me?
A: By implementing the checklist, you can help to save patients’ lives and decrease
complications, be on the forefront of the surgical safety movement, and be a leader in
your hospital.
9. Q: Our budget is very tight. How can we implement the checklist?
A: Using the checklist requires very minimal resource commitment. Reproduction and
distribution of the checklist is the main financial cost. There is some need for personnel
commitment at the beginning, but once the checklist has spread it should sustain itself.
10. Q: How much does it cost to implement the checklist?
A: The checklist is free to download, but will require input of human resources in order
to implement it hospital-wide. Please read the starter kit, available on the website, to get a
sense for the level of commitment this venture will require. Many of the elements of the
checklist, such as a verification of patient’s identification, require no money to implement
and could save the hospital thousands of dollars by preventing surgical mishaps. Other
items on the checklist, such as the use of antibiotics from 0 to 60 minutes prior to
incision, make sure that resources that hospitals already have are used to their fullest
potential.
11. Q: We are already very busy in the operating room. Isn’t this just one more task using
up valuable time?
A: Once the checklist has become familiar to the operating teams, it requires very little
extra time to perform. Most of the steps are incorporated into existing workflow and the
remainder will add only one or two minutes to the OR time. However, the checklist can
also save time be ensuring better coordination between the teams, minimizing slowdowns
for tasks like retrieval of additional equipment.
12. Q: While there is enthusiasm amongst some clinicians for the checklist, there are others
who do not see the value of this initiative. Can we still use the checklist?
A: Yes. Implementation should always begin with the most enthusiastic. Go after the
“low hanging fruit,” those who are interested in improvement. The checklist can be
implemented by an individual clinician in cases in which he or she participates, a selected

service or operating room suite at a hospital, or on a hospital-wide or even system-wide
basis. Focus energy on those areas and individuals who are receptive to the idea at first
and as they become accustomed to the checklist and its benefits, they will help it spread
to their peers.
13. Q: We are interested in improving our hospital’s performance in some perioperative
measures not included on the checklist. How can we do this?
A: The checklist, while intended to be universally applicable, is not always a perfect fit
for all institutions. Modifications can be made to include items that are deemed essential.
However, we would caution against making the checklist too comprehensive. The more
items added to it, the more difficult it will be to successfully implement.
14. Q: How can I convince administrators/clinicians that this is worth doing?
A: As part of our “Starter Kit,” we’ve included a section called, “Questions for Hospitals
to Answer Prior to Implementing the Checklist.” Having the baseline data this form is
designed to collect will enable you to demonstrate to the administration any weaknesses
in the perioperative process and later see how far you have come with regard to outcome
and process measures. We highly recommend not simply using the checklist, but
measuring how that use changes the way surgery is practiced.
15. Q: I have additional questions not covered by the FAQ. Can I speak to someone?
A: We are currently setting up a network of mentors who have successfully implemented
the checklist. Please contact us at [email protected] for more information
Last updated: May 27, 2009