By: 30 October 2018
Barriers to the implementation of the Surgical Safety Checklist

Jennifer Blakelidge talks about the success and barriers following the creation of the WHO standardised Surgical Safety Checklist (SSC)



The World Alliance for Patient Safety [1] identified surgery as the most complex intervention in healthcare, stating that well known safety principles are inconsistently applied; this motivated the creation of the WHO standardised Surgical Safety Checklist (SSC).

Studies have consistently demonstrated reductions in mortality and morbidity due to the use of surgical checklists. Despite its success, issues have arisen with compliance, engagement and the continuation of serious preventable surgical incidents known as ‘never events’ [2, 3].

The WHO checklist was developed from the aviation industry in which checklists have been in use following a Boeing 299 crash in 1935 [4].The National Patient Safety Agency [5] introduced the ‘five steps to safer surgery’ which added two further sections to be used alongside the SSC to further reduce complications. Sixty-six per cent of health related adverse effects within developed countries occur during surgery with 4 per cent leading to death [6].

An international comprehensive study found a decrease in mortality rates from 1.5 per cent to 0.8 per cent after the implementation of the SSC [7]. Many authors agree that implementation of the checklist significantly reduces postoperative morbidity and mortality [7, 8, 9]. SSC compliance varies greatly from 8.8 per cent to 87.4 per cent in previous observational studies [10-13].

The WHO checklist is 10 years old and some have suggested that it lacks clarity [14] and requires modification as it is not effective as it should be [15]. Additional tools and checks have been created to use alongside the SSC, such as ’10,000 feet’ [16] and ‘Sterile cockpit’ [17] to improve patient outcomes. The SSC is designed to be used worldwide and its simple checklist style approach to potentially complex issues could necessitate from the need for it to be accessible to both developing and developed countries [18].

The public expect minimised risk in healthcare [19]. Seventy-five per cent of people want the SSC used in their operations, with 66 per cent believing it reduces error [20]. In practice there is minimal explanation given to patients for why the checks are being conducted. This can lead to frustration from patients [14]. Prentice [21] contends that checklists move knowledge of complex procedures into a tick box form, which could lead to lack of engagement from staff. O’Brien et al., indicate that despite the checklist’s national introduction in 2009, it is still fraught with challenges during use [8]. The NHS England Patient Safety Association[24] notes that 362 perioperative incidents known as ‘never events’ occurred between April – December 2017, and of these 297 were related to surgery. This implies that the SSC is not working as effectively as intended, to reduce these poor outcomes. Locally, when ‘never events’ have occurred, this has led to changes to the SSC along with searching the aviation industry for additional improvements which are transferrable to theatre.

Several key issues with meaningful use of the SSC were identified including non-technical skills, the checklist itself, additional tools and hierarchy of theatre staff.


Non-Technical skills

Non-technical skills in perioperative practice include communication, teamwork, leadership, decision-making and situation awareness [25]. Checklist literature highlights communication as the most important factor in successful SSC implementation. Although some have shown a low adherence to checklists resulting in surgical delays [22] and hindrance to workflow [26], there is evidence to suggest that the surgical checklists are associated with improved communication, detection of safety issues and decreased complications for patients [14]. Benham et al, documented 24 preventable sources of delay being picked up by the use of SSC [27].

Prentice [21] highlights that the biggest threats to complex systems are the result of human rather than technical failures, adding that checklists may risk turning surgery into a system, with individual differences being overlooked. Kilduff et al., [10] adds that reliance on checklists may create non-engagement with safety protocols and cause a culture of reliance on interventions rather than understanding of how human factors influence outcomes. An awareness of human error as a factor in poor surgical outcomes has been noted since the 1890s, during studies on safe use of ether and chloroform [28]. The SSC could be seen as simplistic as it does not acknowledge individual differences. The SSC questions are basic and there is no scope for expansion on the checklist. This is likely due to its worldwide roll out and it has been set out in this way to ensure it is accessible in developing countries.

Russ et al., [20] observed team members were 43.4 per cent more compliant and likely to pause when SSC was conducted by the surgeon compared to 20.1 per cent of the time if it was conducted by a nurse. This highlights the importance of establishing checklist leadership. Communication within the team is often overlooked in SSC literature with the focus of successful SSC implementation being awarded to the surgeon and anaesthetists for their role in its adoption. Failings in non-technical skills such as communication and teamwork could be a contributory factor in adverse events in theatres [25, 29]. The literature suggests that hierarchical bias could cause the theatre team to disengage with the checklist which ultimately leads to it becoming meaningless [25, 29, 30].

Behavioural change is required for the SSC to be successfully integrated into the theatre setting [20]. This must come from all members of the multidisciplinary team. Some authors [35] argue that change which is imposed on people is often met with opposition due to feelings of loss of control. Sullivan and Garland [36] highlight the importance of leadership, management, early team involvement and willingness to change, to create a lasting positive attitude towards the SSC. This builds on DeLorenzo’s [37] argument that lasting change requires planning and commitment. DeLorenzo, Sendlehofer et al, [38] and Amos et al, [35] suggest the original WHO [1] guidelines were vague and imply this has created leadership and involvement issues at all levels within the theatre team.

Russ et al, [20] highlights the need for human factor training but makes no suggestion of what to include and how to deliver it. Timmons et al, [39] highlight that successful human factor training could be stalled due to the non-accommodating culture of health care with those at the top of the hierarchy unwilling to change their practice to accommodate those further down. O’Brien et al, [8] notes the need for designated roles within the theatre team and highlights that the WHO [1] guidelines refer to team involvement but provide no indication of how to create a non-hierarchical team.

Mahajan [15] highlights hierarchy of staff as a potential barrier to successful implementation, noting higher checklist compliance when led by a surgeon or anaesthetist. Saturno et al, [13] found a higher compliance with the SSC when the surgical team had a positive attitude and staff were more likely to comply if the surgeons were engaged. Carney et al, [44] note that team members who are perceived as higher in the theatre hierarchy are less likely to feel their behaviour needs to change, particularly as those with high self-esteem may resist suggestions of flaws in their capabilities [45] or lead to a perceived loss of power or status [15]. Aerden et al, [45] highlight the aviation industry’s blame-free reporting culture and note that it is the opposite within healthcare; with surgeons unlikely to report mistakes due to fear of litigation, and believing it harms their professional reputation. The literature suggests that the SSC is to be used as a tool for all staff and involves the whole team to ensure patient safety and fear of blame and avoidance of completing the SSC oppose the reasoning for the SSC creation [1, 17, 45].


Sign In, Time Out and Sign Out

The WHO SSC [1] is separated into three sections, ‘sign in, time out and sign out’. The NPSA [5] ‘five steps to safer surgery’ added a ‘brief’ and ‘debrief’ section to the start and end of each theatre list. This compliments the SSC and is used along with it to promote safer informed team work [18]. Nilsson et al, [40] suggest the introductions of team members is necessary to support the team in feeling free to speak up if they have concerns. The SSC focuses on patient and equipment checks and there is no supporting literature from WHO [1] on potential discomfort felt by staff when asking these questions.

Sign in

The ‘sign in’ section of the checklist is used to confirm patients’ identity, surgical procedure, site and consent to operate. The WHO [1] state that the surgeon should be present for this section of the SSC, however Gitelis et al, [42] note that members of the multidisciplinary team (MDT) are often in different locations at the start of the list making SSC completion more difficult. This has implications for the patient as the anaesthetic staff may not understand the consent form or require clarification of surgical site marking prior to anaesthetic induction. Similarly, the patient may have final questions they wish to ask the surgical team. Several authors [14, 43] contend that the checklist could cause unnecessary patient anxiety due to repetition of patient detail checks immediately prior to induction.

Time out

The ‘time out’ section is intended to create a pause with the whole team present immediately prior to skin incision [14]. Literature agrees that the ‘time out; is where most critical safety items are checked [3, 13, 32, 44]. All agree that this section of the SSC requires clear communication from all team members. Several authors [19, 18] highlight questions being dismissed or missed out if deemed irrelevant by the team. Saturno et al, [13] further add that items were often acknowledged but not considered carefully, Nolan et al, [32] note vagueness in this section of the SSC and clarification of answers is often required. Mahajan [15] argues that inappropriate wording of checklists often lead to dismissive replies. This is seen when asking for potential blood loss which is often met with responses such as ‘limited’ and ‘minimal’ which have no defined amount and are subject to interpretation. This is in line with Vats et al, [12] who note that anaesthetists and nurses attitudes are largely positive towards the SSC with surgeons seen as unenthusiastic. The literature indicates a lack of understanding of the importance of each question and staff appear unaware that each question is mandatory [13, 18, 19].

Sign Out

The ‘sign out’ section of the SSC is designed to review the operation. Issues such as equipment malfunctions or difficulty in performing the surgery are noted and post-operative management is discussed. This should take place with all team members present and prior to surgeons stepping away from the operating table [1]. Prentice [21] discusses the importance of acknowledging the complexity of individuals’ anatomy and suggests the standardisation of checklists overlooks this. The literature suggests a wide range of uptake levels for the SSC which could imply that it is seen as irrelevant in some cases [2, 18]. Reed et al, [18] highlight the ‘sign out’ section as the least likely to be followed with key members not present in 67-83 per cent of cases observed, they surmise this is due to staff feeling other patient orientated tasks have higher priority at this time. As the SSC is locally adaptable, there are issues with reliability as each study could find different results when using a slightly different SSC; an updated SSC and review are required to ensure its relevance.


Additional checklist tools

Several tools derived from the aviation industry have been developed to assist in the effective use of SSC and successful patient outcomes. Current literature suggests that not all health care documents should be derived from the aviation industry as there are several key differences which need to be taken into account [17, 45].

Kapur et al, [46] note that checklists from the aviation industry are specific for each aircraft whereas the SSC is a generic document used for all procedures. Aerden et al, [45] add that pilots have a major interest in adhering to the safety checklists as they would pay for any oversight with their own lives. Webster [4] argues that while aircraft are complicated, patients are complex and that individual differences should not be overlooked. Surgeons and anaesthetists often highlight potential complications which may arise due to previous surgeries, radiotherapy and pre-existing co-morbidities. None of which are present on the checklist as a cue to raise concerns. This implies further thinking and analysis for each patient is required alongside following the simple prompts listed on the SSC. Prentice [21] notes that the SSC treat the surgical team as components of a socio-technical system and argues that human bodies are not easily standardised like airplanes. Webster [4] supports this stating that while majority of eventualities can be predicted for an aircraft this is not the case for humans.

Locally, recent ‘never events’ have led to the adoption of the ’10,000 feet’ tool [16]. The term ‘Below Ten Thousand’ originated from existing ‘Sterile Cockpit’ literature [17] and refers to the time, when there is a greater risk of an aviation issue. Gibbs & Smith [16] suggest that ‘Below Ten Thousand’ is an early escalation tool and can be used by any team member as it is non-confrontational and non-conflictory. The ‘10,000 feet’ tool has been introduced to compliment the SSC and is designed to add an extra layer of safety during surgical procedures.



The SSC has been proven to be effective in reducing harm during the perioperative period [7, 20, 21]. Literature highlights barriers to effective implementation and use of the SSC [14, 22, 34]. Haugen et al, [41] note that the use of SSC is reliant on team work, communication and cohesion. Without these the SSC becomes a tick box exercise. SSC’s simplistic nature is deliberate to promote its accessibility by all nations worldwide with options for specialisation where required; however, this has led to questions seen as irrelevant by those in the developed world.

Non-technical skills such as good communication, are essential in theatre [25, 45]. Staff hierarchies are noted [15] as a potential barrier to successful implementation. The use of additional tools such as 10,000 feet and ‘five steps to safer surgery’ suggest the SSC is not effective on its own. Lack of enthusiasm for the checklist’s success [20, 21, 38] is highlighted as a barrier to meaningful completion. Amos et al, [35] highlight the need for behavioural change to come from the team and not purely imposed by management. Anaesthetists have a key role to play as part of the MDT in relation to the implementation and successful adoption of such proposed safety measures.


Key points

  • The World Alliance for Patient Safety identified surgery as the most complex intervention in healthcare, this lead to the creation of the WHO Surgical Safety Checklist in 2008. Despite being in use for 10 years it is still fraught with challenges. Additional tools have been created and implemented to support the initial SSC, however there has been no further SSC developments from WHO.
  • Barriers to implementation include non-technical skills such as communication, behaviour and hierarchy of staff; the checklist itself has been criticised for being vague and containing irrelevant questions for those working in the developed world.
  • The checklist is made up of three sections, each with its own set of issues. The sign in section often occurs without the full team present, the time out section is seen as the most important but the wording of the document often requires clarification and additional information adding. The sign out section is noted for low adherence as there is no set time for it to occur and staff are often engaged in other tasks.
  • Additional tools which were developed from the aviation industry have been criticised as the SSC is a generic document whereas aviation checklists are specific for each aircraft. Authors argue that an aircraft is complicated but a person is complex. The ‘10,000 feet’ tool has been introduced to add an extra layer of safety during surgical procedures, however it has been met with mixed attitudes from staff at all levels.
  • Staff attitudes to further guidelines and additional tools are a potential barrier to implementation, this is due to imposed changes being met with feelings of loss of control. Leadership, management and early team involvement are essential in creating a lasting positive change.



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Author: Jennifer Blakelidge RN, MARCH, BSc, DipHE