Patient safety checklists

Evidence Rating  
Scientifically Supported
Evidence rating: Scientifically Supported

Strategies with this rating are most likely to make a difference. These strategies have been tested in many robust studies with consistently positive results.

Health Factors  
Decision Makers

Patient safety checklists are visual tools to prompt safe practices, standardize communication, and ensure no step is forgotten before or during a medical procedure1. Checklists can be used to support patient safety during surgical procedures, handoffs between health care providers, or in other health care situations2, 3.

Expected Beneficial Outcomes (Rated)

  • Increased adherence to clinical guidelines

  • Improved coordination of care

  • Improved patient safety

Other Potential Beneficial Outcomes

  • Reduced mortality

  • Reduced patient complications

Evidence of Effectiveness

There is strong evidence that patient safety checklists increase adherence to best practice guidelines and safety measures1, 4, 5, 6, and improve teamwork and communication among providers1, 6, 7. Checklists can also reduce adverse patient events6.

Surgical checklists can reduce patient mortality1, 8, 9, 10 and surgical site infection2, 8, and may reduce blood loss2. Such checklists can also reduce postoperative complications2, 7, 8, 9, 10 and re-operation7, especially when surgical teams adhere closely to the checklist7, 9.

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 included11. In some circumstances, postoperative checklists for handoffs between providers can reduce errors and information omissions, which could lead to diagnostic or treatment delays and adverse patient events3. In emergency departments and intensive care units, checklists may reduce the length of patient stays8 and improve adherence to best care practices6, 8.

A Netherlands-based study suggests mortality risk may not decline among patients whose checklists are not completed in full12. Experts suggest monitoring checklist compliance to ensure adherence5, 9, 13. Studies of implementation in the United States, United Kingdom, and the Netherlands indicate that checklist compliance varies14, 1512; 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 adherence7.

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 $117.

Impact on Disparities

No impact on disparities likely

Implementation Examples

Checklist use is widespread, especially for high-risk procedures such as surgery13. The University of Washington’s surgical checklist program16 and the Barnes-Jewish Hospital wrong site surgery prevention system17 are two examples of checklist adoption initiatives in the United States. Many checklist initiatives are based on the World Health Organization (WHO) checklist2,9, and the SURPASS checklist7. The WHO surgical checklist takes about two minutes to complete per use7.

Implementation Resources

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.

AHRQ-WHO checklist - Agency for Healthcare Research and Quality (AHRQ). WHO surgical safety checklist and implementation manual 2009 edition.

SafeSurgery* - Barnes C, Berry W, Edmondson L, Childers AK. Safe Surgery Checklist Implementation Guide. Boston, MA: Ariadne Labs; 2015.


* Journal subscription may be required for access.

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 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.

5 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.

6 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.

7 Treadwell 2014* - Treadwell JR, Lucas S, Tsou AY. Surgical checklists: A systematic review of impacts and implementation. BMJ Quality & Safety. 2014;23:299-318.

8 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.

9 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.

10 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.

11 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

12 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.

13 AHRQ-Checklists - Agency for Healthcare Research and Quality (AHRQ). Patient safety primers.

14 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.

15 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.

16 AHRQ HCIE-Dellinger - Dellinger E. Checklist-guided process reduces surgery-related mortality and complications. Rockville: AHRQ Health Care Innovations Exchange.

17 AHRQ HCIE-Chole - Chole RA. Checklist-plus-technology system eliminates wrong-site surgery and near-misses, enhances required preoperative process compliance. Rockville: AHRQ Health Care Innovations Exchange.

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