Patient safety checklists
Patient safety checklists are visual tools to prompt safe practices, standardize communication, and ensure no step is forgotten in a health care situation1. Checklists can be used to support patient safety before, during, and following surgical procedures; during handoffs between health care providers; or in other health care situations2, 3; and may be integrated into electronic medical records4. Checklists, especially in operating rooms, are intended as a “time-out” during which providers set aside other tasks to focus on patient safety concerns5, 6.
What could this strategy improve?
Expected Benefits
Our evidence rating is based on the likelihood of achieving these outcomes:
Increased adherence to clinical guidelines
Improved coordination of care
Improved patient safety
Reduced mortality
Reduced patient complications
Potential Benefits
Our evidence rating is not based on these outcomes, but these benefits may also be possible:
Reduced health care-associated infections (HAIs)
What does the research say about effectiveness?
There is strong evidence that patient safety checklists increase adherence to best practice clinical guidelines1, 7, 8, 9, 10 and improve coordination of care, including teamwork and communication among providers1, 5, 7, 11, 12. They improve patient safety by reducing adverse patient events5, 7, 11 and patient complications5, 13.
Surgical safety checklists reduce patient mortality1, 5, 14, 15, 16 and surgical site infections5, 17. Such checklists can also reduce postoperative complications5, 15 and re-operations5, especially when surgical teams adhere closely to the checklist12, 14, and may also reduce blood loss5. Preoperative checklists can increase the likelihood that needed equipment is available, configured correctly, and will function properly during an operation, especially when an equipment check is included18. Anesthesia-specific checklists reduce human error, improve patient safety and teamwork among providers, and increase quality of care; additional evidence is needed to identify ideal checklist components11. In some circumstances, postoperative checklists for handoffs between providers can reduce errors and information omissions, which could otherwise lead to diagnostic or treatment delays and adverse patient events3. A study of a regional hospital system suggests adding surgical safety checklists to the electronic health record may reduce length of stay and 30-day readmission rates4.
Checklists can be customized according to specialty, patient population, or setting and may be created to respond to new conditions or situations19. For example, a New York-based study of a checklist for all infants leaving the NICU for surgery appeared to reduce perioperative hypothermia13. In emergency departments and ICUs, checklists may reduce the length of patient stays17 and improve adherence to best care practices7, 17. A neurocritical care unit checklist can reduce the rate of new infections and hospital length of stay10.
A Netherlands-based study suggests mortality risk may not decline among patients whose checklists are not completed in full20. Experts suggest monitoring checklist compliance to ensure adherence8, 14. Studies of implementation in the U.S., Canada, United Kingdom, and the Netherlands indicate that checklist compliance varies20, 21, 22, 23; ongoing training, management support, an introduction process that captures staff input and tailors the checklist, and a dedicated site champion are also suggested approaches to ensure adherence12.
One study suggests that staff time spent instituting a surgical checklist is valued at less than the cost of a major surgical complication; per-use cost of a checklist is estimated to be $11 in 2008 dollars12.
How could this strategy advance health equity? This strategy is rated inconclusive impact on disparities.
It is unclear what impact patient safety checklists can have on disparities in health care outcomes.
Patients who are Black, Hispanic, American Indian, or Alaska Natives may be at a higher risk of negative postoperative outcomes than patients who are white25. Patients who are Black may also be more likely to be readmitted to the hospital following surgery25, 26 or discharged to a rehabilitation center than patients who are white26. Designing patient safety checklists with these gaps in mind may support positive patient outcomes25; experts suggest that checklists may be used to integrate health equity into patient safety efforts27.
What is the relevant historical background?
In 2008, the World Health Organization (WHO) Safe Surgery Saves Lives initiative released a 19-item checklist which reduced surgical mortality and postoperative complications by improving teamwork and communication, and prioritizing patient safety in all types of operations28, 29. Patient safety checklists are now used in clinical areas beyond surgery27.
Equity Considerations
- What differences in post-surgical outcomes do you see across your patient population? How could these outcomes be changed by implementing patient safety checklists?
- How can your administrators of your hospital or hospital system partner with all types of providers (e.g., doctors, physician assistants, nurses, aids, etc.) to understand what forms of support are needed for smooth implementation and modification of patient safety checklists?
- Who may serve as interdisciplinary champions for patient safety checklists within and across teams, hospital units, or health care systems?
Implementation Examples
Implementation Resources
‡ Resources with a focus on equity.
WHO-SSC - World Health Organization (WHO). Safe surgery: Tool and resources. WHO Surgical Safety Checklist (SSC).
AHRQ-Checklists - Agency for Healthcare Research and Quality (AHRQ). Patient safety primers.
AHRQ-Checklists toolkit - Agency for Healthcare Research and Quality (AHRQ). Checklist toolkit.
CDC-Infection checklist - Centers for Disease Control and Prevention (CDC). Guide to infection prevention for outpatient settings: minimum expectations for safe care and checklist.
SSC Implementation guide 2015 - Safe Surgery Checklist (SSC) Implementation Guide. Boston, Massachusetts: Ariadne Labs; 2015.
Footnotes
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1 Lyons 2014 - Lyons VE, Popejoy LL. Meta-analysis of surgical safety checklist effects on teamwork, communication, morbidity, mortality, and safety. Western Journal of Nursing Research. 2014;36(2):245-261.
2 Gillespie 2014 - Gillespie B, Chaboyer W, Thalib L, et al. Effect of using a safety checklist on patient complications after surgery. Anesthesiology. 2014;5(6):1380-1389.
3 Segall 2012 - Segall N, Bonifacio AS, Schroeder RA, et al. Can we make postoperative patient handovers safer: A systematic review of the literature. Anesthesia and Analgesia. 2012;115(1):102-15
4 Gitelis 2017 - Gitelis ME, Kaczynski A, Shear T, et al. Increasing compliance with the World Health Organization Surgical Safety Checklist—A regional health system’s experience. American Journal of Surgery. 2017;214(1):7-13.
5 Sotto 2021 - Sotto KT, Burian BK, Brindle ME. Impact of the WHO Surgical Safety Checklist relative to its design and intended use: A systematic review and meta-meta-analysis. Journal of the American College of Surgeons. 2021;233(6):794-809e8.
6 Kocher 2020 - Kocher NJ, Schilling A, Hollenbeak C, Raman JD. Impact of a preoperative safety checklist on perioperative quality outcomes and operative efficiency. Urology Practice. 2020;7(6):502-506.
7 Thomassen 2014 - Thomassen Ø, Storesund A, Søfteland E, Brattebø G. The effects of safety checklists in medicine: A systematic review. Acta Anaesthesiologica Scandinavica. 2014;58:5-18.
8 Arriaga 2013 - Arriaga AF, Bader AM, Wong JM, et al. Simulation-based trial of surgical-crisis checklists. The New England Journal of Medicine. 2013;368(3):246-253.
9 Calland 2011 - Calland JF, Turrentine FE, Guerlain S, et al. The surgical safety checklist: Lessons learned during implementation. The American Surgeon. 2011;77(9):1131-1137.
10 Escamilla-Ocanas 2022 - Escamilla-Ocañas CE, Torrealba-Acosta G, Mandava P, et al. Implementation of systematic safety checklists in a neurocritical care unit: A quality improvement study. BMJ Open Quality. 2022;11(4):e001824.
11 Saxena 2020 - Saxena S, Krombach JW, Nahrwold DA, Pirracchio R. Anaesthesia-specific checklists: A systematic review of impact. Anaesthesia Critical Care and Pain Medicine. 2020;39(1):65-73.
12 Treadwell 2014 - Treadwell JR, Lucas S, Tsou AY. Surgical checklists: A systematic review of impacts and implementation. BMJ Quality & Safety. 2014;23:299-318.
13 Hanna 2020 - Hanna M, Htun Z, Islam S, et al. A quality improvement initiative to improve perioperative hypothermia rates in the NICU utilizing checklists. Pediatric Quality and Safety. 2020;5(5):e367.
14 Bergs 2014 - Bergs J, Hellings J, Cleemput I, et al. Systematic review and meta-analysis of the effect of the World Health Organization surgical safety checklist on postoperative complications. The British Journal of Surgery. 2014;101:150-158.
15 Biccard 2016 - Biccard BM, Rodseth R, Cronje L, et al. A meta-analysis of the efficacy of preoperative surgical safety checklists to improve perioperative outcomes. South African Medical Journal. 2016;106(6):592-597.
16 Haynes 2017 - Haynes AB, Edmondson L, Lipsitz SR, et al. Mortality trends after a voluntary checklist-based surgical safety collaborative. Annals of Surgery. 2017;266(6):923-929.
17 Ko 2011 - Ko HCH, Turner TJ, Finnigan, MA. Systematic review of safety checklists for use by medical care teams in acute hospital settings: Limited evidence of effectiveness. BMC Health Services Research. 2011;11:211.
18 Weerakkody 2013 - Weerakkody RA, Cheshire NJ, Riga C, et al. Surgical technology and operating-room safety failures: A systematic review of quantitative studies. BMJ Quality & Safety. 2013;22:710-718
19 Starr 2022 - Starr NE, Moore JN, Shreckengost CSH, et al. Perioperative provider safety in the pandemic: Development, implementation and evaluation of an adjunct COVID-19 Surgical Patient Checklist. Anaesthesia and Intensive Care. 2022;50(6):457-467.
20 van Klei 2012 - van Klei WA, Hoff RG, van Aarnhem EEHL, et al. Effects of the introduction of the WHO “Surgical Safety Checklist” on in-hospital mortality: A cohort study. Annals of Surgery. 2012;255(1):44-49.
21 Levy 2012 - Levy SM, Senter CE, Hawkins RB, et al. Implementing a surgical checklist: More than checking a box. Surgery. 2012;152(3):331–336.
22 Mobilio 2022 - Mobilio MH, Paradis E, Moulton C. “Some version, most of the time”: The surgical safety checklist, patient safety, and the everyday experience of practice variation. American Journal of Surgery. 2022;223(6):1105-1111.
23 Russ 2015 - Russ S, Rout S, Caris J, et al. Measuring variation in use of the WHO surgical safety checklist in the operating room: A multicenter prospective cross-sectional study. Journal of the American College of Surgeons. 2015;220(1):1-11.e4.
24 WHO-SSC - World Health Organization (WHO). Safe surgery: Tool and resources. WHO Surgical Safety Checklist (SSC).
25 Abella 2023 - Abella MKIL, Lee AY, Agonias K, et al. Racial disparities in general surgery outcomes. Journal of Surgical Research. 2023;288:261-268.
26 Azin 2020 - Azin A, Hirpara DH, Doshi S, et al. Racial disparities in surgery: A cross-specialty matched comparison between Black and white patients. Annals of Surgery Open. 2020;1(2):e023.
27 AAMC-Haskins 2019 - Haskins J. AAMC News: 20 years of patient safety. Association of American Medical Colleges (AAMC); 2019.
28 Panda 2021 - Panda N, Haynes AB. Effective implementation and utilization of checklists in surgical patient safety. Surgical Clinics of North America. 2021;101(1):37-48.
29 WFSA-Woodman 2016 - Woodman N. Patient Safety Tutorial 325: World Health Organization Surgical Safety Checklist. World Federation of Societies of Anesthesiologists (WFSA); 2016.
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