The Effect of the WHO Surgical Safety Checklist on Patient Mortality:
A Literature Review
Camille Dela Rosa
Azusa Pacific University
GNRS 507: Scientific Writing
Dr. Tracy Layne
November 19, 2021
The Effect of the WHO Surgical Safety Checklist on Patient Mortality:
A Literature Review
Communication breakdown is one of the leading causes of patient mortality in the
operating room (OR) each year (Ugur et al., 2016). Without effective communication amongst
OR staff, surgical deaths continue to be a world-wide issue (Weiser & Haynes, 2018). As a result
of increasing patient mortality rates, the World Health Organization (WHO) developed the WHO
Surgical Safety Checklist (WHO SSC) to improve communication, patient safety, and outcome
(de Jager et al., 2019; O’Brien et al., 2016). The purpose of this paper is to conduct a literature
review on the effect of the WHO SSC on patient mortality. The studies will be reviewed based
on methodology, sampling, research findings, and study limitations.
According to Ugur et al. (2016), one in every 50 patients die from preventable adverse
events with two-thirds of these events occurring in the OR. Today, many ORs do not have an
effective safety checklist in place resulting in adverse events. One of the leading causes of
preventable adverse events in the OR is communication breakdowns (Ugur et al., 2016). In order
to address these adverse events, the WHO SSC was developed to improve surgical patient safety,
prevent adverse events, and reduce surgical deaths (de Jager et al., 2019; O’Brien et al., 2016).
Despite the evidence that the WHO SSC has shown to reduce patient mortality,
challenges continue in implementing the surgical checklist (Mahajan, 2011). One of the
challenges includes feelings of anxiety from OR team members who are unfamiliar with the
WHO SSC process. Another barrier includes the misuse of the checklist. For example, nurses
have a significant role in providing effective communication between the OR team to ensure
patient safety. However, when surgeons and/or anesthesiologists have a perception that safety
checklists delay surgery, this may add pressure on nurses to quickly move through the checklist
(Mahajan, 2011). Although the implementation of the WHO SSC in hospitals has been a slow
progress, there is evidence to support its success in reducing patient mortality rates. For example,
a study conducted in all acute hospitals in Scotland found that the use of the WHO SSC had
significantly reduced patient mortality (Ramsay et al., 2019). This literature review provides a
brief critical evaluation and overview related to the PICOT (population, intervention,
comparison, outcome, time) question: In surgical patients, what affect does the WHO SSC,
compared to not using the WHO SSC, have on mortality rates after one year?
The studies included in this literature review conducted various research designs. Three
studies performed a randomized controlled trial (RCT) (Chaudhary et al., 2015; Haugen et al.,
2015; Naidoo et al., 2017). Ramsay et al. (2019) and Mastracci et al. (2013) utilized cohort
studies. Penataro-Pintado et al. (2020) conducted a qualitative study. Treadwell et al. (2013)
performed a systematic review. Each study evaluated the effects of the WHO SSC on patient
mortality differently. In response to the increase in surgical deaths, the WHO developed a
clinical practice guideline (CPG) known as the WHO Guidelines for Safe Surgery 2009: Safe
Surgery Saves Lives, which is also included in this literature review.
Inconsistency in the type of RCT used was identified in the studies conducted by
Chaudhary et al. (2015), Mastracci et al. (2013), and Naidoo et al. (2017). While Chaudhary et
al. (2015) conducted a prospective RCT, Mastracci et al. (2013) performed a stepped wedge
cluster RCT to prevent contamination effects and potential challenges in distributing the WHO
SSC intervention to participants (such as financial challenges). On the other hand, Naidoo et al.
(2017) used a stratified cluster RCT in which participating hospitals were stratified into district
hospitals or regional hospitals prior to randomizing patients into the intervention or control
group. Due to the inconsistency in the type of RCT used amongst the three studies, it is difficult
to determine which type of RCT is most effective in preventing selection bias. Despite the
differences in the RCTs, all three studies found a significant decrease in patient mortality after
implementation of the WHO SSC (Chaudhary et al., 2015; Haugen et al., 2015; Naidoo et al.,
While most of the studies in this literature review used the standard version of the WHO
SSC for the independent variable, two studies used a modified version of the WHO SSC.
Chaudhary et al. (2015) utilized a modified WHO SSC for the independent variable in which the
standard version included two additional steps. The additional steps included whether imaging
studies had been discussed with the radiologist during the “sign-in” phase of the checklist and
whether prophylactic measures against deep vein thrombosis were administered during the “sign-
out” phase. Naidoo et al. (2017) also used a modified version of the WHO SSC to improve
maternal surgical outcomes. Due to the modified checklists used by Chaudhary et al. (2015) and
Naidoo et al. (2017), generalizability for both studies is reduced. Despite the modifications, both
studies found a decrease in patient mortality with the use of the WHO SSC.
Most of the studies measured patient mortality as the dependent variable; however, one
study did not. Rather than measuring patient mortality, the study conducted by Penataro-Pintado
et al. (2020) measured nurses’ perception on surgical patient safety after implementation of the
WHO SSC. This study used a qualitative design which presented with limitations because it was
not able to provide data on surgical deaths. Although Penataro-Pintado et al. (2020) did not
measure patient mortality, the researchers identified that nurses perceived the WHO SSC
important in order to improve patient safety and outcomes (Penataro-Pintado, 2020).
Most of the studies in this literature review used a large sample size of surgical patients;
however, three studies did not. Chaudhary et al. (2015) used a sample size of 700 patients.
Naidoo et al. (2017) used a sample size of 510 patients. Penataro-Pintado et al. (2020) included a
sample size of perioperative nurses (not surgical patients). The large sample sizes used in the
studies by Haugen et al. (2015), Ramsay et al. (2019), and Mastracci et al. (2013) provides
greater generalizability. On the other hand, the small sample sizes used by Chaudhary et al.
(2015) and Naidoo et al. (2017) lowers generalizability. Penataro-Pintado et al. (2020) did not
use a sample size of surgical patients, which limits the support for the PICOT question. Despite
the differences in the sample sizes, most of the studies showed a significant decrease in patient
mortality with the use of the WHO SSC (Mastracci et al., 2013; Chaudhary et al., 2015; Haugen
et al., 2015; Naidoo et al., 2017, Ramsay et al., 2019).
Differences were identified in the surgical units and country the studies were conducted
in. Chaudhary et al. (2015) included patients from a gastrointestinal and hepato-pancreato-biliary
(HPB) unit from one tertiary care hospital in India. Haugen et al. (2015) included five different
surgical departments (e.g., general, cardiothoracic, orthopedic, neurosurgery, and urologic
department) from two hospitals in Norway. Naidoo et al. (2017) included the maternal surgical
unit from 18 different hospitals in South Africa. Ramsay et al. (2019) included all acute hospitals
that were only based in Scotland. Mastracci et al. (2013) included a patient population from a
single hospital in the Netherlands. Due to the differences in the surgical specialties, external
validity is reduced. The varying countries between the studies also lowers generalizability.
Nevertheless, the studies showed a decrease in patient mortality with the WHO SSC intervention
(Mastracci et al., 2013; Chaudhary et al., 2015; Haugen et al., 2015; Naidoo et al., 2017; Ramsay
et al., 2019).
Most of the studies showed a significant decrease in patient mortality after
implementation of the WHO SSC (p<0.05); however, one study did not show a significant
decrease. In the study conducted by Naidoo et al. (2017), patient mortality had a p-value of
0.444, which does not show a significant decrease. Although the study did not show a significant
decrease in surgical deaths, the results still showed a decrease in mortality indicating the positive
effects of the WHO SSC on patient safety and outcome.
While most of the studies focused on the results of the WHO SSC intervention on patient
mortality and postoperative complications, one study found the WHO SSC implementation was
not always completed by the OR staff. Chaudhary et al. (2015) found that the checklist was fully
completed for 85% of the patients (n=298), partially completed for 10% (n=34), and not
completed for 5% (n=24). The fact that Chaudhary et al. (2015) included compliance of the
WHO SSC as an additional dependent variable and found that not everyone adequately
completes the checklist increases internal validity.
The major limitations of the studies identified in this literature review include
inconsistency in the sample sizes, differences in the population (e.g., surgical department and
country), and perception of the WHO SSC. The small sample sizes used by Chaudhary et al.
(2015) and Naidoo et al. (2017) lowered generalizability. The qualitative study conducted by
Penataro-Pintado et al. (2020) showed limitations in the support for the PICOT question, since
the sample size consisted of perioperative nurses and not surgical patients. Although the
Treadwell et al. (2013) utilized 33 studies in their systematic review, the researchers did not
mention how many surgical patients in total were included. The varying surgical departments
and countries in which the studies were conducted lowered generalizability (Mastracci et al.,
2013; Chaudhary et al., 2015; Haugen et al., 2015; Naidoo et al., 2017; Ramsay et al., 2019).
While many nurses perceived the WHO SSC essential to patient safety, it is clear that some
nurses did not by providing partial or incomplete checklists (Chaudhary et al., 2015; Penataro-
Pintado et al., 2020).
Clinical Practice Guideline
WHO developed a clinical practice guideline (CPG) known as the WHO Guidelines for
Safe Surgery 2009: Safe Surgery Saves Lives. The CPG aims to reduce surgical deaths around
the world. To reduce patient mortality, WHO emphasizes the importance of their CPG as it
addresses safe anesthetic practices, effective communication amongst OR team members, and
prevention of surgical infections. The WHO Guidelines for Safe Surgery 2009: Safe Surgery
Saves Lives includes the WHO SSC and recommends the importance in using the checklist to
reduce patient mortality.
This literature review evaluates the effect of the WHO SSC on patient mortality. Despite
the inconsistency in sample sizes, population, and perception of the WHO SSC, the studies found
reduced patient mortality with the use of the checklist. The research findings provide evidence-
based information and supports the PICOT question.
Maybe include your rating of the CPG for quality?
Chaudhary, N., Varma, V., Kapoor, S., Mehta, N., Kumaran, V., & Nundy, S. (2015).
Implementation of a surgical safety checklist and postoperative outcomes: A prospective
randomized controlled study. Journal of Gastrointestinal Surgery, 19(5), 935-942.
de Jager, E., Gunnarsson, R., & Ho, Y. (2019). Implementation of the World Health
Organization Surgical Safety Checklist correlates with reduced surgical mortality and
length of hospital admission in a high-income country. World Journal of Surgery, 43,
Haugen, A. S., Softeland, E., Almeland, S. K., Sevdalis, N., Vonen, B., Eide, G., Nortvedt, M.
W., & Harthug, S. (2015). Effect of the World Health Organization checklist on patient
outcomes: A stepped wedge cluster randomized controlled trial. Annals of Surgery,
Mahajan, R. P. (2011). The WHO surgical checklist. Best Practice & Research Clinical
Anaesthesiology, 25, 161-168.
Mastracci, T. M., Greenberg, C. C., Kortbeek, & J. B. (2013). What are the effects of introducing
the WHO “surgical safety checklist” on in-hospital mortality? Journal of the American
College of Surgeons, 217(6), 1151-1153. https://www.journalacs.org/article/S1072-
Naidoo, M., Moodley, J., Gathiram, P., & Sartorius, B. (2017). The impact of a modified World
Health Organization surgical safety checklist on maternal outcomes in a South African
setting: A stratified cluster-randomised controlled trial. Southern African American
Journal, 107(3), 248-257. https://www.ajol.info/index.php/samj/article/view/153312
O’Brien, B., Graham, M. M., & Kelly, S. M. (2016). Exploring nurses’ use of the WHO safety
checklist in the perioperative setting. Journal of Nursing Management, 25(6), 468-476.
Penataro-Pintado, E., Rodriguez, E., Castillo, J., Martin-Ferreres, M. L., De Juan, M. A., &
Agea, J. L. D. (2020). Perioperative nurses’ experiences in relation to surgical patient
safety: A qualitative study. Nursing inquiry, 28(2), 1-14.
Ramsay, G., Haynes, A. B., Lipsitz, S. R., Solsky, I., Leitch, J., Gawande, A. A., & Kumar, M.
(2019). Reducing surgical mortality in Scotland by use of the WHO surgical safety
checklist. British Journal of Surgery, 106(8), 1005-1011.
Treadwell, J. R., Lucas, S., & Tsou, A. Y. (2013). Surgical checklists: A systematic review of
impacts and implementation. BMJ Quality & Safety, 23(4), 299-318.
Ugur, E., Kara, S., Yildirim, S., & Akbal, E. (2016). Medical errors and patient safety in the
operating room. Journal of Pakistan Medical Association, 66(5), 593-597.
Weiser, T. G., & Haynes, A. B. (2018). Ten years of the surgical safety checklist. British Journal
of Surgery Society, 105(8), 927-929.
World Health Organization. (2009). WHO guidelines for safe surgery 2009: Safe surgery saves
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