Madam,

I read with interest the review entitled "WHO safe surgery checklist: Barriers to universal acceptance."\[[@ref1]\] The World Alliance for Patient Safety initiated work on the challenge of surgical safety in January 2007. The World Alliance published World Health Organization Surgical Safety Checklist (WHO SSC) and Implementation Manual in June, 2008.\[[@ref2]\] It is amusing to note that 10 years after its introduction in clinical practice, the issue needs to be reviewed because it is still not universally followed.

The authors have reviewed the published articles citing barriers in the implementation of WHO SSC. The authors have focused their manuscript on contemporary publications. It is indeed most disturbing to note that a major reform introduced by the world\'s apex healthcare regulator, to ensure safe surgery, has still not been accepted by a large part of the medical world and we are still seeking to review why this prime initiative has still not been adopted.

Unfortunately, large teaching institutes have failed to join the WHO SSC bandwagon due to a detached and apathetic attitude toward patient safety, despite the fact that surgical errors are more common in teaching hospitals. The hierarchical system in the teaching hospitals and disconnect between the patient and the operating team result in major errors. Patients are seen by unit member in the outpatient and after admission, days or months later, are worked up by another member. On the day of the surgery, the unit member working up the patient may not be posted in the operating room. Errors of wrong patient, side and site occur as the surgeon has the first look at the patient on the operating table. The WHO SSC is therefore an inescapable requirement to prevent wrong surgery.

The benefits of following the WHO SSC are well established and profound.\[[@ref3]\] The benefits are particularly immense in low and medium income countries such as India, where medical infrastructure and manpower is inadequate and the health system is strained by a huge patient load.\[[@ref4]\] Errors are regular and so is public uproar against doctors in these countries. The pressure to complete colossal surgical lists results in wrong site and organ surgeries on a regular basis. To prevent these mishaps, following WHO SSC is thus far more important in these countries than in the developed world.

There is a need to critically analyze the reasons why institutions have failed to implement WHO SSC. The reasons cited in this review, for nonimplementation, are lame excuses to cover the deficiencies in the institutions. The primary reason for noncompliance is a callous and indifferent attitude of doctors. The WHO SSC is a simple checklist that hardly needs anytime to complete and excuses, such as it being time-consuming, cannot be acceptable. Noncompliance of the WHO SSC protocol is due to a mental barrier and not due to functional issues. The suggestion that its use be initiated in a phased manner is not practical. The implementation of the protocol must be across board in all institutions, by diktat, and no excuses must be entertained. Anesthesiologists, being custodians of the operation theater, should promote the safety culture and ensure that no patient is exposed to surgery before sign-in and time-out and that the surgical team does not leave the operating room before sign-out. Patient safety is paramount and there can be no compromise on this.

Financial support and sponsorship {#sec2-1}
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Nil.

Conflicts of interest {#sec2-2}
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There are no conflicts of interest.
