in 2009 , the world health organization ( who ) published the surgical safety checklist ( ssc ) as part of their safe surgery saves lives campaign . the checklist was adapted from the field of aviation , where checklist use is standard practice . in aviation , checklists were developed in response to a crash involving an experienced pilot operating a new airplane with features that were significantly different from previous models . shortly after takeoff ,
an investigation revealed that the pilot had forgotten to perform one of the steps necessary for takeoff . in response ,
the checklist was created to prevent future avoidable disasters.(1 ) with more than 200 million operations performed annually , the who recognized the importance of addressing surgical safety when the checklist was introduced .
the purpose of the checklist was to help operating room ( or ) teams remember important details that may be missed during an operation .
in addition , it served as a tool to encourage teamwork and communication.(2 ) in a sense , the who came to the same conclusion that the plane crash investigation team had : even highly skilled or teams need tools to help them achieve optimal results . the initial who ssc
was piloted at eight diverse hospitals around the world and contained 19 items that were to be addressed at defined time points during the operation ( figure 1).(3 ) the items included in the ssc are aimed at preventing uncommon but serious errors by reminding the team to confirm patient identity , surgical site , and other important characteristics such as comorbid conditions or anticipated complications . results from the initial prospective , sequential , time - series observational study showed significant reductions in complications , in - hospital mortality , rates of unplanned reoperation , and surgical site infection ( ssi ) compared to pre - checklist rates .
( 4 ) since then , the who ssc has been implemented in more than 4,000 hospitals worldwide.(5 ) hospitals are encouraged to customize the checklist to their needs , but the general format remains the same .
studies validating these various checklists have continued to show , for the most part , a benefit when the ssc or similar checklist is used , ( 611 ) but the mechanism by which this occurs is unclear .
recent high - profile reports have highlighted the pitfalls of sscs , such as inconsistent implementation and compliance.(12 ) in an era of increasing complexity of care , it appears that the checklist is serving as a conduit for improved teamwork and communication through which the improved outcomes result .
the aim of this paper is to review the literature related to ssc use as a communication tool , with a focus on how the checklist is associated with team behaviors and attitudes in the or .
in addition , we describe scenarios where use of the ssc is associated with changes in patient outcomes .
we reviewed studies that have been collated by the senior author , who has extensively studied the fields of or safety , communication and checklist use for the past 10 years .
we included studies that addressed the use of the checklist as a tool for improved communication in the or , with an emphasis on changes in both team behaviors and clinical outcomes after implementation .
additional studies were selected that described compliance with the ssc and how it may be affected by variations in implementation strategy .
safety within the or is an important public health concern . it is estimated that of the complications that occur within the hospital setting , more than half are associated with surgical procedures.(13 ) every operation has a series of steps that must be performed correctly every time : surgeons must use the correct equipment , the equipment must be available and in proper working order , and drugs need to be administered in a timely and appropriate fashion .
as their roles in an operation are interdependent , it is incumbent on the anesthesia team , the nursing staff , and surgeons to communicate effectively to prevent avoidable complications such as wrong site surgery and inappropriate antibiotic administration . despite this
, research has shown that surgeons , anesthesiologists , and nurses have rather different concepts of what constitutes teamwork and communication in the or.(14 , 15 ) one study used the safety attitudes questionnaire ( saq ) to assess perception of patient safety in the or .
the saq is a standardized survey that uses a five - point likert scale to measure items such as teamwork and safety.(16 ) this particular study found that women reported significantly lower aggregated scores than men on the domain  teamwork climate  ( 69 vs 76 , p<0.05 ) .
( 17 ) a separate study investigated specific aspects of teamwork and found that nurses reported significantly lower scores than surgeons regarding reception of nursing input ( 3.8 vs 4.3 , p<0.001 ) , ability to voice concern ( 3.5 vs 3.7 , p=0.03 ) , and whether physicians and nurses work well as a team ( 3.3 vs 3.7 , p<0.001 ) .
( 14 ) the consequences of this disparity can be serious . in one study investigating reports of wrong site surgery , or
pooled results predicted that in cases with the potential for wrong - site surgery , concerns would be raised and addressed only 41% of the time.(18 ) while wrong site surgery is an uncommon event , communication failures are common , occurring every 78 minutes and affecting up to 30% of interactions in the or.(19 , 20 ) for a routine case lasting 23 hours , this means that up to 25 attempts at communication may be unsuccessful .
use of a checklist may prevent more than half of communication failures from occurring ( 21 ) by orienting the team to the individual patient , alerting each member to potential complications , and encouraging team members to voice concern when they notice an error occurring .
one of the primary arguments in favor of checklists is that they help to decrease surgically associated morbidity and mortality , and can be implemented in most settings .
use of system - wide checklists can improve compliance with other metrics , such as increased timely antibiotic administration , decreased unexpected delays in the schedule , and reduced time spent outside of the or gathering supplies during an operation.(2123 ) timely antibiotic administration has been linked to a decrease in surgical site infection . in one study ,
pre - incision antibiotics were not administered 12.1% of the time ; after introduction of a checklist , this number decreased to 7.1% ( p=0.015).(23 ) while introducing the checklist can initially be viewed as disruptive , staff members typically have a favorable attitude after it has been initiated.(24 ) substantial work has been undertaken to understand if the use of checklists actually improves communication in the or . in a pilot study investigating the utility of pre - procedural briefing in cardiac surgery ( similar to the who ssc ) , the number of miscommunication events declined by 50% in the briefing group compared to the group that did not use the briefing tool.(21 ) other studies have found that communication failures declined by two thirds after initiation of a surgical briefing.(24 ) in a study investigating pre- and post - implementation scores using the saq , respondents were more likely agree that checklists are important for safety ( 4.58 vs 4.79 , p=0.0058 ) , and they were more likely to report a culture that encouraged team members to voice concern ( 4.02 vs 4.21 , p=0.0225 ) . additionally , 93.4% of the clinicians who responded to the survey stated that if they were undergoing an operation , they would want the checklist used.(25 ) critics of the ssc have noted that while use of the checklist may identify problems , the person conducting the checklist is ultimately responsible for resolving the problem and redirecting the team.(26 ) for example , if the checklist demonstrates that the patient did not receive appropriate antibiotics in a timely fashion , the surgeon , anesthesiologist , and circulating nurse must rectify this mistake prior to proceeding with the operation . this begins to address an important concern : while the checklist itself might be improving patient safety , there may be something different about teams who routinely use the checklist .
checklists are rarely comprehensive enough to catch every possible error . instead , proper use of the checklist may be a marker for teamwork and cooperation within the or .
regardless of checklist use , the link between team behaviors and patient safety is well recognized .
infrequent use of team behaviors ( defined in one study as  briefing ,   information sharing ,   inquiry ,   vigilance and awareness ,   assertion ,  and  contingency management  ) is associated with increased risk of death and other complications,(27 ) while high levels of communication and collaboration are associated with overall lower rates of risk - adjusted morbidity.(28 ) other evidence shows a correlation between increased teamwork and a lower frequency of errors during an operation.(29 ) wiegmann , in examining when errors in the or are discovered and by whom , concluded that while poor teamwork can lead to errors , good teamwork leads to the detection and correction of mistakes.(30 ) investigators have attempted to describe the link between checklist use and improved patient outcomes .
one explanation is that use of the checklist improves the safety culture within an institution by facilitating communication .
makary and colleagues administered an or based version of the saq to assess changes after implementation of an or briefing protocol .
respondents reported increased scores on items such as awareness of surgical site brought about by the briefing ( 3.74 vs 3.18 , p<0.001 ) , coordinated efforts by surgical staff and anesthesia staff ( 4.54 vs 3.68 , p<0.000 ) , and on the importance of the briefing to patient safety ( 3.24 vs 2.75 , p<0.001).(31 ) however , checklist implementation may introduce new challenges that had not previously been considered . in a viewpoint discussing checklist use , rydenfalt contends that merely introducing a checklist without monitoring compliance may actually make the or less safe because previous safety checks are dropped.(32 ) or staff have reported in interviews that use of the checklist can interrupt the performance of other safety tasks that are simultaneously being performed by individuals .
additionally , without a firm sense of commitment to the checklist it may become a routine activity of checking off boxes without actually driving behavior change or improvement .
( 33 ) running through the list in such fashion may give or staff a false sense of security that issues have truly been resolved when in fact they have not .
( 34 ) without providing team members proper instruction regarding the use and value of the checklist , it may actually become a nuisance to the or staff . while there is a significant amount of data showing that checklist use leads to improvements in patient outcomes ,
investigators have also performed checklist audits to evaluate how the or team uses the ssc in everyday practice .
levy and colleagues examined the efficacy of the checklist for ensuring performance in the or and found that administrative records confirmed 100% performance while auditing by observers in the or recorded less than 50% completion for most elements , and in some cases less than 10% of the checklist elements were completed.(35 ) subsequently , the same group organized safety workshops as well as a stakeholder engagement group to customize the checklist for local concern . with these two interventions , overall adherence improved from 30% to 96% ( p<0.001).(36 )
a recent report raised serious questions about the utility and effectiveness of surgical checklists . in 2010 , the canadian province of ontario mandated that each hospital use the who ssc and that they report their compliance . in this real - world observational study , hospitals were evaluated before and after implementation of the ssc .
change in surgical mortality was the primary outcome , but the investigators also looked at other outcomes such as morbidity and readmission .
the results of the study showed that despite widespread adoption of the who ssc , there was no significant difference in mortality ( 0.71% vs 0.65% , p=0.13 ) or surgical complications ( 3.86% vs 3.83% , p=0.29 ) .
( 12 ) it is unclear why the results of the ontario study were so different from the original who study . the findings sparked a debate about what the surgical community should expect from the ssc , and whether its use was directly associated with a change in outcome .
one of the criticisms of the ontario study was related to implementation strategy , as it seemed that individual hospitals were responsible for implementation without being given administrative support . in the who ssc study , the task of implementation required considerable resources and support in order to be effective .
additionally , there was concern that compliance with the ssc was likely lower than what it had been in previous studies so the expected effects were not realized.(37 ) despite operational flaws , many say that the findings from ontario should be seriously considered , as the observational nature of this study is likely to be characteristic of typical use of the checklist.(38 , 39 ) the results found in the rigorously controlled environment of a randomized controlled trial do not always approximate the effects that are seen in  real world 
conditions , which may explain why there was no difference in morbidity or mortality rates in ontario .
additionally , simply telling people to change their behavior without providing any guidance or support on how to do so may not be the most effective strategy .
the modern surgical environment is complex , and communication errors are relatively common . as described , used of the ssc has become common throughout the world .
while checklists show promise in the reduction of surgical morbidity and mortality , there is also evidence that these improvements are not realized without careful attention to implementation strategy .
when deciding to implement checklists in the or , administrators should assess the climate of their hospital in order to make the checklist relevant to those who will be using it rather than an additional hurdle to jump over .
providing feedback to teams regarding patient outcomes and or performance may be a valuable strategy to promote buy - in at the provider level.(33 ) in addition , encouraging customization of the checklist to fit the needs of the team may promote a feeling of ownership over the checklist , increasing compliance along the way .
( 33 , 36 ) without the support of staff members , it is unlikely that the checklist will lead to any changes in patient outcomes . for now , the surgical community should view the checklist as a tool for improving communication and safety culture , and be realistic about its direct impact on patient safety .
 existing evidence suggests that communication failures are common in the operating room , and that they lead to increased complications , including infections . 
 use of a surgical safety checklist may prevent communication failures and reduce complications . 
 initial data from the world health organization surgical safety checklist ( who ssc ) demonstrated significant reductions in both morbidity and mortality with checklist implementation . 
 a growing body of literature points out that while the physical act of  checking the box  may not necessarily prevent all adverse events , the checklist is a scaffold on which attitudes towards teamwork and communication can be encouraged and improved . 
 recent evidence reinforces the fact the compliance with the checklist is critical for the effects on patient safety to be realized . 
1. The Surgical Safety Checklist
2. Communication Lapses are Common
3. The Checklist can Improve Communication and Teamwork
4. Is it the Checklist or the Teamwork?
5. Case Study
6. Conclusion