The use of checklists in surgery: a paper tiger or a cost-effective life-saving device?

The use of checklists in surgery: a paper tiger or a cost-effective life-saving device?
De Faoite D, Hanson B

Objective: Healthcare professionals are increasingly under pressure from different stakeholders to reduce healthcare costs. However, new technologies often come at a high price. The use of simple checklists has been advanced as a low-tech, low-cost way to improve surgical performance. We wanted to investigate if this has proven to be the case.

A two-pronged review of the literature was conducted. In a first stage, general information about checklists was collected from a variety of medical and non-medical sources. A comprehensive PubMed search was conducted to locate articles which reported on the health and financial outcomes once a checklist had been implemented. In addition, information on the acceptance of checklists was also extracted.

Methods: General: Checklists should only be used for simple problems. Their main advantage is acting as a cognitive aid to ensure that all of the main elements for a procedure have been addressed-for even experts forget!

Attitudes: Surgeons and surgical teams may be reluctant to use checklists at first, suggesting that attitudinal change is required for their widespread acceptance. In addition to this, changes in practice have to be integrated into daily routines. There are strategies available on how to inculcate a checklist culture in a clinic. However, once in use, the majority of the surgical team appears to appreciate the benefits that checklists bring and its use very quickly reaches nearly full compliance. Large improvements in inter-team communication have also been recorded.

A Road to Damascus type conversion was also anecdotally reported several times whereby a previously strident opponent of checklists realized that the checklist had helped identify a problem in the operating room. As a result, they learned to appreciate the value of checklists.

Results: Checklists have a wide application among different disciplines and even just asking people to create one leads to improved results. An international study on the WHO Safe Surgery Checklist recorded a fall in complications in surgical patients from 11% to 7% and a fall in mortality from 1.5 to 0.8%, while other studies recorded similar improvements in outcomes.

Conclusions: Worldwide research demonstrates the effectiveness of the use of checklists in surgery. The WHO estimates that up to 500,000 patients per year could avoid fatal complications if its Safe Surgery Checklist was implemented in all cases. Checklists require careful content planning and rollout in clinics, however, they do bring noticeable and at times dramatic improvements. Checklists should also be continually adapted and evolve to suit a clinic’s present situation.


Deutscher Kongress für Orthopädie und Unfallchirurgie (DKOU 2014). Berlin, 28.-31.10.2014. Düsseldorf: German Medical Science GMS Publishing House; 2014. DocWI56-555

doi: 10.3205/14dkou407urn:nbn:de:0183-14dkou4071

Published: October 13, 2014
© 2014 De Faoite et al.
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