Surgical Safety Checklist

Effectiveness of the Surgical
Safety Checklist in Correcting

Errors: A Literature Review Applying
Reason’s Swiss Cheese Model
SUSAN J. COLLINS, DNP, RN; ROBIN NEWHOUSE, PhD, RN; JODY PORTER, DNP, MBA, RN;
AKKENEEL TALSMA, PhD, RN
ABSTRACT
Approximately 2,700 patients are harmed by wrong-site surgery each year. The
World Health Organization created the surgical safety checklist to reduce the inci-
dence of wrong-site surgery. A project team conducted a narrative review of the
literature to determine the effectiveness of the surgical safety checklist in correcting
and preventing errors in the OR. Team members used Swiss cheese model of error
by Reason to analyze the findings. Analysis of results indicated the effectiveness of
the surgical checklist in reducing the incidence of wrong-site surgeries and other
medical errors; however, checklists alone will not prevent all errors. Successful
implementation requires perioperative stakeholders to understand the nature of
errors, recognize the complex dynamic between systems and individuals, and create
a just culture that encourages a shared vision of patient safety. AORN J 100 (July
2014) 65-79. Ó AORN, Inc, 2014. http://dx.doi.org/10.1016/j.aorn.2013.07.024
Key words: checklists, surgical safety checklist, patient safety, OR safety, medical
errors, preventable adverse events, error prevention, teamwork, just culture, Swiss
cheese model.
making errors.2 Medical errors place patients at
A
lthough more than a decade has passed
since the 1999 release of the Institute great risk of harm.3 Examples of errors and adverse
of Medicine report To Err Is Human: events related to surgical procedures are wrong
Building a Safer Health System,1 there remains anatomic site, incorrect procedure, equipment
ample need for the use of standardized processes failure or malfunction, administration of an anti-
to reduce the risk of human error, thereby im- biotic despite a noted allergy, nerve damage related
proving patient care. The OR is characterized by fast- to positioning, implantation of orthopedic appli-
paced activity, numerous distractions, a hierar- ances that are not appropriately sterilized, post-
chical reporting structure, advanced technology, operative development of deep vein thrombus
and complex equipment, all of which can affect related to incorrect placement of sequential com-
health care professionals, making them prone to pression devices, and retained sponges.4
http://dx.doi.org/10.1016/j.aorn.2013.07.024
Ó AORN, Inc, 2014 July 2014 Vol 100 No 1 AORN Journal j 65
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July 2014 Vol 100 No 1 COLLINS ET AL
In recent years, there has been a strong focus on narrative review of the literature related to surgical
eliminating wrong-site surgeries. Of 7,147 sentinel checklists. Members of the project team included
events reported from 1995 to 2010, The Joint Com- doctoral students, capstone committee members, a
mission5 identified 956 cases of wrong-site surgeries nurse manager, and a perioperative RN. The goal of
(13.4%), with communication breakdowns reported the project was to determine the effectiveness of
as the main cause of such errors. In 2008, in an attempt surgical checklists in correcting and preventing error-
to reduce the risk and occurrence of wrong-site prone processes in the OR as well as to identify the
surgery, the Centers for Medicare & Medicaid types of errors that lead to adverse outcomes.
Services6 announced that it would no longer re-
imburse institutions for surgical errors related to SURGICAL SAFETY CHECKLISTS
wrong-site surgery or retained surgical objects. In 2004, the magnitude of the wrong-site surgery
This change in reimbursement policy was driven problem14 was evident from the number of sentinel
by data indicating that 48% of all surgical compli- events being reported. According to The Joint
cations are preventable. 7,8 Commission, wrong-site surgery was the most
Surgical safety also is an international focus. Ac- common sentinel event reported between 2004 and
cording to the World Health Organization (WHO),9 2010.15 In response to this patient safety issue, the
each year approximately 234 million major surgical WHO developed and implemented a surgical safety
procedures are performed worldwide, which is one checklist, which it updated in 2009.16 The surgical
operation for every 25 people alive. In the United safety checklist applies to three phases of surgery:
States, there are more than 48 million inpatient before induction of anesthesia, before skin incision
surgical procedures10 and more than 53 million (ie, time out), and before the patient leaves the OR.
ambulatory procedures performed annually.11 In Running safety checks at each phase involves all
industrialized countries, for example, the United members of the surgical team, whereby the team
States, analysis of data has shown the rate of conducts a verification process, and all members
major complications associated with inpatient must be in agreement with one another before the
surgery to range from 3% to 17% and the rate procedure can continue. Team validation has been
of deaths to range from 0.4% to 0.8%.7,8 shown to reduce errors in perioperative processes.7
Analysis of errors by Reason12 revealed that most Versions of the WHO surgical checklist are in
accidents are rarely the result of isolated errors use at the global, national, and state levels to pro-
committed by individuals but instead are the result mote patient safety in the OR. The United Kingdom,
of multiple, smaller errors occurring in an environment for example, mandated the use of this checklist
with fundamental system flaws.13 The Swiss cheese in every hospital,17 and, in 2008, the Institute
model by Reason12 illustrates this type of occurrence for Healthcare Improvement18 called for all US
but also that a system with multiple checks can prevent hospitals to use the surgical safety checklist in at
errors. According to the Swiss cheese metaphor, the least one of their ORs. The Safe Surgery 2015
slices of cheese are layered and each layer is a defense initiative at the Harvard School of Public Health,
(eg, the surgical safety checklist) against the holes in Boston, Massachusetts, is committed to all hos-
the cheese, which represent a problem or error in the pitals in the United States routinely using a version
system (eg, active and latent failures). The more of the checklist in their ORs by 2015. This initiative
layers of cheese, the less likely it is that the holes has three focal points: preventing wrong-site sur-
will line up for an error to occur (Figure 1).12 gery, reducing surgical-site infections, and reducing
The importance of systems’ contributions to pa- complications.19 Additionally, in 2013, the Centers
tient safety and adverse outcomes prompted members for Medicare and Medicaid Services announced
of a project team to apply the model by Reason12 to a that ambulatory surgery centers and hospitals
66 j AORN Journal
SURGICAL CHECKLISTS AND ERRORS www.aornjournal.org
Figure 1. Adaptation of the Swiss cheese model by James T. Reason to illustrate how the use of the surgical
safety checklist may prevent active and latent failures. Source: Reason J. Human error: models and manage-
ment. BMJ. 2000;320(7237):768-770.
needed to report on whether their personnel used Although the use of surgical safety checklists is
a surgical safety checklist during the previous year.20 becoming more common in US hospitals, various
According to The Joint Commission, organizations process failures continue to occur. Adoption of a
are expected to assess safe patient practices and checklist alone does not guarantee accuracy because
effective communication during each of the three errors may result because of deviations from policies
phases of surgery identified on the checklist; annual and procedures. Although periodic, comprehensive
payments to the organization may be reduced if a audits of checklists can further help to reduce med-
checklist is not used.21 ical errors, the effectiveness of a surgical checklist
AORN Journal j 67
can be understood within a larger framework of n failure to perform regular testing of equipment,
errors when using the Swiss cheese model of errors which then may malfunction during surgery; and
by Reason.12 n effects of time pressures that interfere with
team members’ productivity, concentration, or
SWISS CHEESE MODEL OF ERRORS effective room usage.
Reason12 reported that, in a complex system such as
Factors that may lead to latent errors include
health care, human error is likely to occur and that
flaws in regulatory or institutional policies and
expecting perfection from imperfect human beings
procedures, problems with leadership, the work
or punishing them for their mistakes will not improve
environment, and inadequate staffing levels relative
safety. The model by Reason12 indicates that the
to the required tasks.22 Addressing latent errors
preferred strategy is either to prevent an error from
requires an understanding of how the system in-
occurring or prevent the error from causing harm
teracts with the individual; the availability of re-
through the application of multiple steps that func-
sources; and the organization’s culture, policy, and
tion as a safety net. High-technology systems, such
procedures. Latent errors can be resolved by using
as the OR, have levels of defense to catch errors
strategies from system theory.12
or prevent them from occurring and causing harm,
including the surgical safety checklist, the surgical Active Errors
team, and policy and procedures. As discussed, each Active errors (ie, sharp-end errors) are the result of
defensive layer can be viewed as a slice of Swiss an individual’s failure and occur at the point of
cheese. Holes are present in several defense layers, contact between a human and an aspect of a larger
and, unintentionally, the holes can line up, allowing system. This type of error generally involves front-
an error to occur. Reason12 posits that the holes in the line personnel and is usually more easily identified
Swiss cheese, or defense layer, are the result of both than a latent error. Examples of active failures include
latent and active errors. The terms latent errors and
n performing surgery on the incorrect limb (ie,
active errors are used to differentiate between sys-
tem failures and individual errors, respectively.12 wrong-site surgery),
n administering the wrong medication,
n programming equipment incorrectly, and
Latent Errors
n placing the incorrect medical gas on the lapa-
Latent errors (ie, blunt-end errors) are the result
roscopy cart.
of organizational system or design failures that
will allow active errors to happen and cause harm. Active errors are generally caused by mental
Latent errors are less apparent than active errors. lapses, errors in judgment, or procedural violations.
For example, a pharmacy’s software may not According to the model by Reason,12 addressing
interface properly with surgical documentation active errors also requires an understanding of how
software, resulting in medications that are not the system interacts with the individual. Furthermore,
reviewed by the pharmacy department before in determining actions to take to prevent active errors
administration. Other examples of latent system from recurring, the cause of the error first must be
errors could include isolated from the error itself.12 Active errors can be
n failure to institute a practice of anticipating the further classified into slips, lapses, and mistakes.
amount of likely blood loss before a surgical Slips and lapses. Reason23 suggested that hu-
procedure begins; man errors involve a deviation in procedure, policy,
n failure to review patients’ allergies routinely or behavior; whereas slips and lapses can occur
before administering antibiotics; during rote performance of routine tasks. The
68 j AORN Journal
distinction between a slip and a lapse is that a slip is personal accountability (ie, what an individual did
24
observable but a lapse is not. Slips and lapses are or did not do correctly). By comparison, the model
generally the result of fatigue, stress, and emotional by Reason12 shifts the focus to systems accountability
13
or sensory distractions. Members of a health care so that an event can be analyzed as a nonlinear, dy-
organization can decrease the occurrence of slips and namic relationship in which the interface between
lapses by reviewing and understanding the work behavior and the event takes place within a larger
environment and implementing protocols and pro- system.26 This shift provides a broader viewpoint
cedures. Using checklists, reducing workarounds, for determining how to prevent the error from
reducing variations in practice, and eliminating recurring.25
distractions are among the strategies used to decrease The model by Reason indicates that all organi-
25
the occurrence of slips and lapses. According to zations are exposed to adverse events to some
the Agency for Healthcare Research and Quality, degree. Perioperative leaders must be both aware
creating a culture of safety is important because it of this inherent exposure and able to recognize it
encourages the report- as a nonlinear com-
ing of active errors and ponent of complex,
facilitates the identi- Using checklists, reducing workarounds, adaptive systems.
fication of latent er- reducing variations in practice, and eliminating Adverse patient out-
22 distractions are among the strategies used to
rors. Creating an comes can be assessed
environment in which decrease the occurrence of slips and lapses. by using the just cul-
health care profes- ture framework. By
sionals are not repri- using this framework,
manded for committing slips or lapses is vital to the incident can be explored beyond the immediate
promoting a safe patient care environment. unsafe action to encompass the core assumptions of
Mistakes. Mistakes are often the result of wrong human behavior and to identify and fix the orga-
choices, inexperience, or procedural violations. nizational conditions that contributed to the nega-
Reducing the occurrence of mistakes generally re- tive outcome. The just culture philosophy is one
quires additional training of the health care worker, that emphasizes the value of becoming a learning
remediation, or disciplinary action. Violations can organization (ie, a subculture within an organi-
be either deliberate (eg, a team member who re- zation that is composed of observing, creating,
fuses to participate in the time out) or unintentional and acting27). Creating a just culture requires trust,
(eg, forgetfulness, not paying attention to a detail). which subsequently establishes and supports a culture
The key difference between slips or lapses and wherein events can be reported, and errors can
mistakes is that a mistake involves doing the wrong be examined, and conclusions reached and actions
thing, whereas a slip or lapse involves doing the taken can be collectively understood. According to
right thing incorrectly. Even though slips or lapses Reason,12 a just culture is essential and must already
occur more frequently than do mistakes, health care be established within the organization to create and
leaders frequently treat slips or lapses as mistakes sustain a safety culture.
and respond by establishing an action plan to pre-
vent mistakes. LITERATURE SEARCH: SURGICAL SAFETY
CHECKLISTS
APPLYING MODEL OF ANALYSIS BY A member of the project team, the perioperative
REASON RN, conducted a search of the literature to identify
When one uses this traditional way of analyzing studies that used a surgical safety checklist to
patient safety and patient outcomes, the focus is on prevent latent and active errors in the OR. The
AORN Journal j 69
perioperative RN gathered evidence by searching pilot study32), one expert opinion,33 and one regulatory
several online databases: EBSCOhostÒ, CINAHLÒ, body statement34 in this section. All the studies
MEDLINEÒ, OvidÒ, and Cochrane Reviews. She received a good-quality rating (Level B). All six
retrieved 65 articles by using the following key sources support that latent errors can be prevented
words: scripting, checklists, safety, error preven- by the use of a surgical safety checklist.
tion, standardized tools, teamwork, aviation, pro- Conley et al29 conducted a qualitative study
tocols, timeout, and guidelines. Exclusion criteria (Level III B) to understand which type of organi-
included articles published before 2002 and studies zational leadership had the greatest effect on the
conducted in nonsurgical settings, which left 38 implementation of a surgical safety checklist. The
articles. The project team reviewed 38 abstracts, research team conducted semistructured interviews
of which 15 met all inclusion criteria (ie, published with leaders responsible for implementation of the
in 2002 or later, conducted in surgical settings, surgical safety checklist and with surgeons. Anal-
included search terms). ysis of findings showed that implementation as a
To assess the 15 evidence sources in terms of team effort was most effective, implementation
strength of design and quality, members of the project by an empowering leader ranked second, and
team used the evidence rating system from The Johns implementation by a laissez-faire leader was least
Hopkins Nursing Evidence-Based Practice Model effective. The team-effort approach incorporated
and Guidelines.28 Ratings used for the strength of collaboration; educational sessions; and opportu-
evidence design ranged from Level I (ie, strongest) nities for feedback, dialogue, and increased staff
to Level V (ie, weakest), and ratings for the quality support. Surgical team members understood the
of individual sources of evidence ranged from A rationale for implementation of the surgical check-
(ie, strong) to C (ie, low). We summarized the list, recognized their own role in patient safety,
individual studies and works included in the liter- and appreciated the organization’s commitment to
ature review, the design and quality of each study, patient safety initiatives, real-time coaching, and
and study results (see Supplementary Table 1 at best practices.
http://www.aornjournal.org). We also synthesized Vats et al30 conducted a six-month, pre-post
the results of the studies in our literature review intervention pilot study (Level III B) of imple-
(Table 1). The presentation of the studies is in the mentation of an adapted version of the WHO Sur-
following order: gical Safety Checklist in a hospital in the United
1. prevention of latent errors involving stake- Kingdom. Health care workers used the checklist in
holder support through the use of and adher- two ORs at the same hospital in which trauma,
ence to a surgical safety checklist; orthopedic, general, and gynecological surgeries
2. prevention of active errors involving commu- were performed. Researchers collected data on
nication and teamwork among team members previous practices to compare against new data
in the OR through the use of and adherence to related to interventions that included having the
a surgical safety checklist; and researchers introduce the checklist by meeting one-
3. prevention of latent and active errors involving on-one with team members, with small groups, and
promotion of patient safety through the use of in large forums. Analysis of the findings suggested
and adherence to a surgical safety checklist. that, when the organization’s key stakeholders (eg,
surgeons, anesthesia professionals) are supportive,
PREVENTION OF LATENT ERRORS: the surgical safety checklist will be completed
STAKEHOLDER SUPPORT thoroughly and the time out will be performed
We summarized four articles (ie, one qualitative,29 correctly. The confidence level of the OR nurse
one pre-post intervention,30 one survey,31 and one also was an important factor related to the
70 j AORN Journal
TABLE 1. Synthesis of Cited Works from the Literature Review
Number of studies/
Outcomes measures evidence levels Study (year) Synthesis of studies
1
Outcomes related to the pre- 6 n Butcher (2011), n Implementation of the surgi-
vention of latent errors n 3 at Level III B Conley et al (2011),2 cal safety checklist was
involving stakeholders by n 3 at Level IV B Vats et al (2010),3 more successful with the
the use of and adherence Dellinger (2009),4 team-effort approach. The
to a surgical safety checklist The Joint Commission team effort used collabora-
(2012),5 Patient Safety tion, educational sessions,
First (2012)6 and opportunities for feed-
back, dialogue, and in-
creased staff support.
n Analysis of findings suggest
that when the organization’s
key stakeholders are sup-
portive, the surgical safety
checklist will be completed
thoroughly and the time out
will be performed properly.
n The factors most important
to successful implementa-
tion were having a clinical
champion (76%), nursing
staff support (75%), and cli-
nicians as key stakeholders
(62%), including the patient.
Outcomes related to the 4 n Lingard et al (2008),7 n Most communication failures
prevention of active errors n 3 at Level II A Sewell et al (2011),8 were experienced by only 1
involving communication by n 1 at Level III B Takala et al (2011),9 team member, usually the
the use of and adherence to Makary et al (2007)10 surgeon.
a surgical safety checklist n Circulating nurses and an-
esthesia professionals re-
ported significantly fewer
communication failures af-
ter implementation of the
surgical safety checklist.
n The results supported the
hypothesis that surgical
teams with higher levels of
communication and collab-
oration have a decreased
risk of wrong-site events.
Outcomes related to the pre- 5 n Haynes et al (2009),11 n Decreased frequency of
vention of latent and active n 2 at Level II A de Vries et al (2010),12 complications after checklist
errors by the use of and n 3 at Level III B Askarian et al (2011),13 implementation.
adherence to a surgical Panesar et al (2011),14 n The review indicated that
safety checklist Sivathasan et al (2010)15 more than 20% of wrong-
site surgeries could be pre-
vented through the use of
the checklist.
(table continued)
AORN Journal j 71
TABLE 1. (continued ) Synthesis of Cited Works from the Literature Review
Number of studies/
Outcomes measures evidence levels Study (year) Synthesis of studies
n Time pressures in the OR
may lead to an error be-
cause team members may
have omitted certain tasks
on the surgical safety
checklist.
n Results indicate that the
decrease in complication
rates in 6 intervention hos-
pitals can be attributed to
the use of the surgical safety
checklist.
n Implementation of the check-
list was associated with con-
comitant reductions in the
rate of patient death and
complications.
1. Butcher L. Wrong-site surgery. Hosp Health Netw. 2011;85(11):34-37, 1.

2. Conley DM, Singer SJ, Edmondson L, Berry WR, Gawande AA. Effective surgical safety checklist implementation. J Am Coll Surg. 2011;212(5):873-879.
3. Vats A, Vincent CA, Nagpal K, Davies RW, Darzi A, Moorthy M. Practical challenges of introducing WHO surgical safety checklist: UK pilot experience.
BMJ. 2010;340:b5433.
4. Dellinger EP. Implementation of the surgical care outcomes assessment program (SCOAP) and the introduction of the WHO/SCOAP surgical safety
checklist. http://www.saferhealthcarenow.ca/EN/Interventions/SafeSurgery/Documents/Workshops/Plenary%20SCOAP%20Checklist%20Dr%20
Dellinger.pdf. Published 2009. Accessed January 23, 2014.
5. Safe surgery checklist. The Joint Commission. http://www.jointcommission.org/safe_surgery_checklist/. Published July 24, 2012. Accessed January
23, 2014.
6. Five steps to safer surgery. In: Implementing the Surgical Safety Checklist: The Journey So Far.. London, UK: Patient Safety First; 2012:2.
7. Lingard L, Regehr G, Orser B, et al. Evaluation of a preoperative checklist and team briefings among surgeons, nurses, and anesthesiologists to reduce
failures in communication. Arch Surg. 2008;143(1):12-17.
8. Sewell M, Adebibe M, Jayakumar P, et al. Use of the WHO surgical safety checklist in trauma and orthopaedic patients. Int Orthop. 2011;35(6):897-901.
9. Takala RS, Pauniaho SL, Kotkansalo A, et al. A pilot study of the implementation of the WHO surgical checklist in Finland: improvements in activities and
communication. Acta Anaesthesiol Scand. 2011;55(10):1206-1214.
10. Makary MA, Mukherjee A, Sexton JB, et al. Operating room briefings and wrong-site surgery. J Am Coll Surg. 2007;204(2):236-243.
11. Haynes AB, Weiser TG, Berry WR, et al. A surgical safety checklist to reduce morbidity and mortality in a global population. N Engl J Med.
2009;360(5):491-499.
12. de Vries EN, Prins HA, Crolla RM, et al. Effect of a comprehensive surgical safety system on patient outcomes. N Engl J Med. 2010;363(20):1928-1937.
13. Askarian M, Kouchak F, Palenik CJ. Effect of surgical safety checklists on postoperative morbidity and mortality rates, Shiraz, Faghihy Hospital, a 1-year
study. Qual Manag Health Care. 2011;20(4):293-297.
14. Panesar SS, Noble DJ, Mirza SB, et al. Can the surgical checklist reduce the risk of wrong site surgery in orthopaedics?dcan the checklist help?
Supporting evidence from analysis of a national patient incident reporting system. J Orthop Surg Res. 2011;6:18.
15. Sivathasan N, Rakowski KR, Robertson BF, Vijayarajan L. The World Health Organization’s “Surgical Safety Checklist”: should evidence-based initiatives
be enforced in hospital policy? JRSM Short Rep. 2010;1(5):40.
successful use of the checklist. The OR nurses Wales to assess the extent to which they had ful-
viewed the hierarchical reporting structure, which filled the requirements of WHO Surgical Safety
can be deeply rooted in many ORs, as a barrier to Checklist implementation.31 Of the 161 hospitals
implementation of the surgical safety checklist. that responded, 77% reported an increase in team-
Compliance with the use of the surgical safety work, 68% reported improved safety, and 41%
checklist during the pilot test ranged from 42% identified more near misses. Respondents indicated
to 80%. that most important to implementation was having
In 2010, the National Patient Safety Agency a clinical champion (76%), nursing staff support
surveyed 167 acute care hospitals in England and (75%), and clinicians as key stakeholders (62%).
72 j AORN Journal
This large survey (Level IV B) supports the need prevented by the use of a surgical safety checklist.
for buy-in from key stakeholders in successful Analysis of these findings indicate that, when key
implementation of a surgical safety checklist. stakeholders within an organization are supportive
Butcher32 reported findings from eight hospitals of the surgical safety checklist, team members
and ambulatory surgery centers that participated will complete the checklist thoroughly and prop-
in the pilot phase of the Center for Transforming erly, and also indicate that implementation efforts
Healthcare project. The purpose of this pilot study related to the surgical safety checklist were more
(Level III B) was to identify the root causes of successful with a team approach, including
wrong-site surgery. The study identified variations collaboration, educational sessions, and opportu-
from the surgical safety checklist as the root cause nities for feedback, dialogue, and increased team
of most errors. At the organizational level, Butcher32 member support.
identified the following issues as the causes of
shortcuts and failures: PREVENTION OF ACTIVE ERRORS:
COMMUNICATION AND TEAMWORK
n senior leadership not being fully engaged;
In this section, we summarize four studies2,35-37
n patient safety not being an organizational
that used quasi-experimental design or nonexperi-
priority;
mental design. Each article received quality ratings
n staff members not feeling empowered or
of Level A or B. All four sources indicate that
supported;
active errors related to breakdowns in communi-
n policy changes not being shared at all staff
cation can be prevented by the use of a surgical
levels; and
safety checklist.
n pressures being put on staff members to improve
Lingard et al2 (Level II A) examined whether
efficiency, thus causing shortcuts and variations
implementation of a surgical safety checklist ac-
from proper practice.
companied by structured OR briefings affected
Dellinger33 reported supportive findings (Level team communications and reduced communication
IV B) in his expert opinion review of the imple- failures by providing the opportunity for problem
mentation of the surgical safety checklist at the identification and resolution. This 13-month quasi-
University of Washington Medical Center, Seattle. experimental study was conducted by using a pro-
Implementation began with 13 general surgeons. spective design with a pre-post intervention survey
Dellinger33 found that implementation required tool in a general OR at a Canadian academic ter-
promotion, support, and role modeling behaviors tiary center. The sample was composed of nurses,
by a well-respected team comprising nursing surgeons, surgical residents, anesthesia professionals,
leaders, anesthesia professionals, and surgeons. and anesthesia care residents. The intervention was
Less attention has been paid to the role of the a structured team briefing by using a surgical safety
patient as a stakeholder in the surgical safety check- checklist. Trained observers used a validation scale
list. However, as noted by The Joint Commission (ie, an information-exchange recording form) to
(Level IV B),34 the patient also has an active role in observe failures in communication and their con-
site verification, patient identification, verification sequences. Examples of failures included late,
of the procedure being performed, and confirmation inaccurate, unresolved, and exclusive communica-
of any allergies. tion. During the study period, there were 295 sur-
To summarize, four articles,29-32 one expert gical safety checklist briefings for observance,
opinion,33 and one regulatory body statement34 along with 172 procedures, 86 of which occurred
all consistently support that latent errors can be before the intervention and the rest of which
AORN Journal j 73
occurred after. Communication failures declined surveyed reported that communications among team
from a mean of 3.95 (standard deviation [SD] 3.20) members had improved.
to 1.31 (SD 1.53) per surgical procedure after the In an international quasi-experimental study
intervention (P < .001). Analysis of the results of (Level II A), Takala et al36 studied the effect of the
this study suggest a causal relationship between surgical safety checklist on improved team com-
communication and safety, supporting the hypoth- munications and improved safety by preventing
esis that the use of a surgical safety checklist errors from occurring. In this prospective pilot study
combined with surgical team briefings reduces the at four hospitals in Finland, the researchers con-
number of communication failures and promotes ducted a pre-postetest design by using a structured,
team communication. multiple-choice questionnaire to gather data from
In a quasi-experimental study (Level II A) con- surgeons, anesthesia professionals, and the circu-
ducted in the United States, Sewell et al35 explored lating nurses in the OR during a six-week period.
the relationship among the surgical checklist, team Researchers collected data before and after imple-
communications, and mentation of the sur-
teamwork. The re- gical safety checklist.
searchers performed One quasi-experimental study suggests a The circulating nurses
a prospective audit of causal relationship between communication reported better com-
checklist use in elec- and safety, supporting the hypothesis that the munications after im-
tive and emergent or- use of a surgical safety checklist combined with plementation of the
thopedic procedures surgical team briefings reduces the number of surgical safety check-
before and after an communication failures and promotes team list. The circulating
educational interven- communication. nurses noted that,
tion at a single-site when applying the
hospital. The inter- surgical safety check-
vention included posting the surgical safety list, the identity of the patient was confirmed more
checklist in the ORs, viewing a compulsory often, 94.2% of the time after implementation
training video, and holding group discussions of the compared with 81.6% before (P < .001). Knowl-
common reasons for errors in the OR and how the edge of the surgical site improved significantly,
surgical safety checklist could assist with pre- increasing from 90.5% before implementation to
venting adverse events. The research team high- 95.3% after implementation (P < .001). The anes-
lighted how the use of a surgical safety checklist thesia professionals also reported awareness of the
could promote a shift in OR culture by flattening names and roles of the team members improved
the hierarchical reporting structure, enhancing after implementation as well as better communica-
teamwork, and emphasizing that all members of the tions among team members and increased discussion
team are responsible for patient safety. Researchers of critical events with surgeons (42.6% after com-
collected preintervention data on 480 orthopedic pared with 22.0% before; P < .001). The surgeons
surgical patients, and postintervention data on reported that the entire team’s awareness regarding
485 patients. In addition, the researchers asked 100 the surgical procedure improved significantly after
surgical team members four questions about their implementation of the surgical safety checklist;
perceptions of the surgical safety checklist before however, they did not report any change in quality
and after the educational intervention. The inter- of communication among the team. There is evi-
vention significantly increased use of the surgical dence that the majority of communication failures
safety checklist, from 7.9% to 96.9% of the time; were experienced by only one team member, usu-
and 76% of the personnel who researchers ally the surgeon, who was often unable to recognize
74 j AORN Journal
the concerns or problems of other team members. be prevented by the promotion and use of a surgical
The circulating nurses reported significantly fewer safety checklist. Each study used quasi-experimental
communication failures after implementation of the or nonexperimental designs, and all received strong
surgical safety checklist (3% after compared with or good-quality ratings.
23% before; P < .001) as did the anesthesia pro- Haynes et al7 in a large international study
fessionals (6% after compared with 13% before; (Level II A) examined the effect of the WHO
P < .05). Surgical Safety Checklist on complications by us-
In a nonexperimental study (Level III B) con- ing a sample of 3,955 patients ages 16 or older who
ducted at a large academic medical center in Bal- were scheduled to undergo noncardiac surgery. The
timore, Maryland, Makary et al37 investigated OR researchers investigated complication rates and
briefings conducted in conjunction with the surgical deaths within 30 days after surgery. The results at
safety checklist and their effect on communica- the eight participating hospitals showed substantial
tions. The five-month study was carried out in a improvement in process measures, including
general OR with nurses, anesthesia professionals, n appropriate antibiotic selection,
and surgeons. The researchers used a pre-postetest n airway evaluation,
design, administering a survey before and after n increased use of the pulse oximeter,
the introduction and initiation of OR briefings in n additional IV catheter insertions based on antic-
combination with the use of a surgical safety check- ipated blood loss,
list. Analysis of survey results indicated that collab- n oral confirmation of the patient’s identity (eg,
oration between the anesthesia professional and the confirmation of the surgical site), and
surgical team yielded the highest gain. The results n completion of the sponge count.
also supported the hypothesis that surgical teams
with higher levels of communication and collabo- There was a significant reduction in mortality, from
ration have a decreased risk of wrong-site surgery. 1.5% before implementation to 0.8% (P ¼ .003)
In summary, four studies2,35-37 demonstrate that after implementation of the checklist. Inpatient
effective communication affects patient safety by complications also declined, from 11.0% before
preventing active errors in the OR. Team briefings implementation to 7.0% (P < .001) after imple-
have a vital role in the successful implementation mentation of the checklist.
of the surgical safety checklist. In addition, re- To examine how adherence to surgical safety
searchers identified obstacles to effective commu- checklist processes was related to complications
nication among team members; most communication and mortality, de Vries et al38 conducted a pre-post
failures reported were experienced by only one intervention prospective study (Level II A) in six
team member, usually the surgeon, therefore im- hospitals in the Netherlands, five of which did not
peding accurate and effective communication receive the intervention and served as a control
among team members. Sources of communication group. For this international study, the researchers
breakdowns among surgical team members are a collected data from October 2007 until March
vital issue that warrants further exploration. 2009, comparing outcomes of 3,760 patients before
implementation of the checklist with outcomes of
3,820 patients after its implementation. The base-
PREVENTION OF LATENT AND ACTIVE
ERRORS: PROMOTION OF THE SAFETY line data that the researchers collected during a
CHECKLIST three-month time frame were from adult patients
The following is a summary of five studies7,17,38-40 who had general surgery and were discharged from
that indicate that both active and latent errors can the hospitals. Implementation of the surgical safety
AORN Journal j 75
checklist was completed during a nine-month Several researchers have investigated the effect
period, after which researchers collected post- of surgical safety checklists on patient safety.
intervention data for another three months. Based Askarian et al,39 in a six-month interventional study
on random sampling, researchers entered 1,146 (Level III B), examined the effects of the surgical
of 4,387 surgical procedures (26%) that used the checklist in reducing surgical complications. Con-
surgical safety checklist into an online data re- ducted in a teaching hospital in Iran, the study in-
pository to measure compliance and complication volved a convenience sample (ie, a nonprobability
rates. They calculated compliance rates in terms sampling) of 144 participants. The hospital had six
of the percentage of items marked on the surgical ORs. The researchers found that the two most vital
safety checklist as being completed and found a phases of the surgical safety checklist were the time
median of 80%. They determined complication out, occurring just before incision, and the sign-out,
rates by comparing the differences between two occurring as the patient prepared to go to the re-
groups: those patients for whom the number of covery room. The researchers noted a 57% decrease
items marked on the in surgical complica-
checklist was above tions with the use of
the median and those Managers at hospitals where the checklist was the checklist. The most
for whom the number used reported that, because of time pressures common documented
marked was below the in the OR, team members may have omitted complication before
median. The compli- certain tasks on the surgical safety checklist, implementation of the
cation rate per 100 resulting in errors. surgical safety check-
patients decreased list was postoperative
from 27.3 (95% con- surgical-site infec-
fidence interval [CI], 25.9-28.7) to 16.7 (95% CI, tions: 10.4% before the intervention compared
15.6-17.9). In-house mortality decreased from with 5.3% after the intervention; however, this was
1.5% before implementation of the checklist to not statistically significant (P > .05). Hospital
0.8% after implementation. Patient outcomes did personnel addressed this problem by adhering to
not change in the five control hospitals. Analysis of the checklist guidelines related to the timing of
the results indicates that the decrease in complica- the prophylactic antibiotic before the surgical
tion rates in the six intervention hospitals can be incision. The study also noted an increase in
attributed to the use of the surgical safety checklist. personnel’s awareness of and compliance with
In addition, they suggest that complication rates the validation process related to the surgical
decrease further when 80% or more of the items checklist. For example, instruments used for the
on the checklist are marked as being completed. surgical procedure met the checklist sterility
17
Sivathasan et al conducted a telephone survey parameters, thereby contributing to the reduc-
(Level III B) of 421 private and public hospitals in tion in postoperative surgical-site infections.
the United Kingdom to determine whether their The researchers attributed the decrease in sur-
ORs were using the WHO checklist. Researchers gical complications primarily to the coopera-
administered the survey before the compulsory tion between the surgeon and the anesthesia
implementation of the WHO checklist took effect. professional.
Managers at hospitals where the checklist was used Panesar et al40 conducted another international
reported that, because of time pressures in the OR, study (Level III B) to investigate how surgical
team members may have omitted certain tasks on safety checklists have been used as a structured
the surgical safety checklist, resulting in errors. communication tool. The researchers retrospectively
76 j AORN Journal
reviewed data on orthopedic surgeries performed be altered; however, the environment in which the
in the United Kingdom in 2008 that resulted in human functions can be controlled to reduce vari-
harm or death to the patient. The data search ability. The surgical safety checklist is a tool that
identified 316 instances of problems, including may be applicable when designing a high-reliability
133 in which wrong-site surgeries were actually system with a focus on error-prone situations
performed. The researchers examined whether a instead of on the individual. The surgical safety
checklist could have decreased the number of checklist, with proper execution, will almost al-
wrong-site surgery events. The incidents of in- ways achieve a fail-safe situation. When using the
terest were surgical safety checklist, the surgical team cannot
perform components of the time out improperly.
n wrong site marked on the consent form,
The Swiss cheese model demonstrates how the
n wrong patient,
surgical safety checklist could be a safety net
n wrong-site prostheses,
against errors.
n wrong site marked on the patient,
n wrong site blocked,
n wrong-site surgery, and CONCLUSION
n wrong site marked on the checklist. Wrong-site surgery is prevalent and harmful to
patients. The Swiss cheese model by Reason 12
By using a 5-point Likert scale (from 1 ¼ “very
identifies this patient safety issue and provides a
unlikely to occur if a checklist had been used” to
framework for identifying the problematic pro-
5 ¼ “very likely to occur if a checklist had been
cesses that lead to errors, including active and
used”), the researchers ranked the incidents. Anal-
latent failures. The surgical safety checklist has
ysis of their findings suggest that the surgical safety
been a successful intervention (ie, a slice of cheese)
checklist could have prevented 28 of the 133
that reduces the recurrence of errors in the OR. This
wrong-site surgeries. Additional analysis indicated
narrative review highlights the importance of using
that communication failures were associated with
a surgical safety checklist and suggests that fun-
inefficiency, team member tension, waste of resources,
damental requirements for successful implementa-
shortcuts, and procedural errors. The researchers
tion include engagement of key stakeholders, a
concluded that structured, formal communication
culture of trust, a shared vision for safety, and
methods such as checklists can improve teamwork
active communication. Broad implementation of a
and promote reliable delivery of care for the sur-
surgical safety checklist can prevent errors, thereby
gical patient.
avoiding adverse events and helping to ensure pa-
In summary, the evidence reviewed from five
tient safety.
studies7,17,38-40 of either strong or good-quality
grading demonstrates that the use of a surgical
SUPPLEMENTARY DATA
safety checklist improves patient safety in the OR.
The supplementary table associated with this article
Analysis of the evidence shows that patient safety
can be found in the online version at http://dx.doi
is improved by preventing active and latent errors
.org/10.1016/j.aorn.2013.07.024.
from occurring.
Editor’s notes: EBSCOhost and CINAHL, Cumula-
DISCUSSION tive Index to Nursing and Allied Health Literature,
Reason27 noted two important concepts about er- are registered trademarks of EBSCO Information
rors: they are recurring and react to the situation, Services, Ipswich, MA. MEDLINE is a registered
not to the individual. The human condition cannot trademark of the US National Library of Medicine’s
AORN Journal j 77
Medical Literature Analysis and Retrieval System, 15. Clark C. Joint Commission unveils wrong site surgery
prevention tool. HealthLeaders Media. July 5, 2011.
Bethesda, MD. Ovid is a registered trademark of http://www.healthleadersmedia.com/page-1/LED-268180/
Ovid Technologies, Inc, New York, NY. Joint-Commission-Unveils-Wrong-Site-Surgery-Prevention
-Tool. Accessed March 17, 2014.
16. Tools and resources. World Health Organization. http://
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Patient Safety First; 2012:2. http://www.patientsafetyfirst

.nhs.uk/ashx/Asset.ashx?path¼/Implementing%20the% Susan J. Collins, DNP, RN, is manager,
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journey%20so%20far%202010.06.21%20FINAL.pdf.
Accessed January 23, 2014. Baltimore Medical Center, Baltimore, MD.
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33. Dellinger EP. Implementation of the surgical care out-
be perceived as posing a potential conflict of in-
comes assessment program (SCOAP) and the introduc- terest in the publication of this article.
tion of the WHO/SCOAP surgical safety checklist. http://
www.saferhealthcarenow.ca/EN/Interventions/SafeSurgery/ Robin Newhouse, PhD, RN, is chair, organiza-
Documents/Workshops/Plenary%20SCOAP%20Checklist tional systems and adult health, and a professor
%20Dr%20Dellinger.pdf. Published 2009. Accessed
January 23, 2014. at the School of Nursing, University of Mary-
34. Safe surgery checklist. The Joint Commission. http:// land, Baltimore, MD. Dr Newhouse has no
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35. Sewell M, Adebibe M, Jayakumar P, et al. Use of the posing a potential conflict of interest in the
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38. de Vries EN, Prins HA, Crolla RM, et al. Effect of a
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39. Askarian M, Kouchak F, Palenik CJ. Effect of surgical fessor of nursing, University of Michigan, Ann
safety checklists on postoperative morbidity and mortal- Arbor, MI, and research investigator at the School
ity rates, Shiraz, Faghihy Hospital, a 1-year study. Qual
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AORN Journal j 79
79.e1 j AORN Journal
July 2014 Vol 100

SUPPLEMENTARY TABLE 1. Descriptions and Evidence Levels of Cited Works
Evidence
Study (year) Study purpose and design Sample and setting methods Results level
Askarian et al (2011)1 n 6-month interventional study to examine n Nonprobability convenience sample of n 57% decrease in frequency of surgical III B
the effects of the surgical safety checklist 144 participants complications after the surgical safety
No 1
in reducing surgical complications n Conducted at a teaching hospital in Iran checklist was implemented
with 6 ORs
Butcher (2011)2 n 9-month pilot study to identify the root n Nonprobability convenience sample n Identified variations from the surgical III B
causes of wrong-site surgery in the OR n Conducted in 8 US hospitals and safety checklist as the root cause of
ambulatory surgery centers errors:
n Partnership between The Joint Com- n lack of site verification when multiple
mission Center for Transforming Health- procedures were performed,

care and 8 hospitals and ambulatory n ineffective hand over,
surgery centers that performed more n primary documentation was not
than 130,000 annual procedures used to verify the patient and site,
n the site marking washed off during
prepping or was not visible after

draping,
n the time out was not performed at
the correct time,

n the time out was performed without
full participation,
n the time out was not performed
when multiple procedures have

multiple providers,
n senior leaders were not fully
engaged,
n inconsistent organizational focus on
patient safety,
n passive personnel,
n personnel who are not empowered
COLLINS ET AL
to speak up,
n policy changes made without staff
involvement,
n the added stress of maintaining a
high procedure volume and the

pressure to perform a task quickly
SURGICAL CHECKLISTS AND ERRORS
SUPPLEMENTARY TABLE 1. (continued ) Descriptions and Evidence Levels of Cited Works
Evidence
Conley et al (2011)3 n Qualitative research project to identify n Nonprobability purposive sample n Showed implementation of the surgical III B
factors in organizational leadership that n Conducted at 5 hospitals in Washington safety checklist was more successful
have the greatest effect on implementa- state with the team-effort approach, including
tion of the surgical safety checklist n collaboration;
n educational sessions;
n opportunities for feedback, dialogue,
and increased staff member support
Dellinger (2009)4 n Expert opinion review of implementation n Nonprobability convenience sample. n Showed implementation of the surgical IV B
of the surgical safety checklist at a facility n Conducted at the University of Wash- safety checklist required promotion,
ington Medical Center, Seattle support, and role modeling of behaviors
by a well-respected team composed of
nursing leaders, anesthesia professionals,
and surgeons
de Vries et al (2010)5 n Prospective study using a pre-post n Random sample of checklists from n Decrease in the complication rate per II A
intervention design to compare out- participating hospitals in the Netherlands 100 patients, from 27.3 (95% CI,
comes of 3,760 patients before imple- n Conducted at 6 intervention hospitals 25.9-28.7) to 16.7 (95% CI, 15.6-17.9)
mentation of the surgical safety checklist and 5 control hospitals in the n Decrease in in-house mortality, from
with those of 3,820 patients after Netherlands 1.5% to 0.8%
implementation n Decrease in complication rates in the 6
intervention hospitals was attributed to
the use of the surgical safety checklist
Haynes et al (2009)6 n Before-and-after quasi-experimental n Nonprobability convenience sample n Implementation of the checklist was II A
study to examine the effect of the World n Conducted in 8 hospitals and cities associated with concomitant reductions
Health Organization (WHO) Surgical (Toronto, Canada; New Delhi, India; in the rate of patient death and com-
Safety Checklist on complications Amman, Jordan; Auckland, New plications
n Hospital participants in the WHO Safe Zealand; Manila, Philippines; Ifakara, n Significant reduction in mortality, from
Surgery Saves Lives Program Tanzania; London, England; and 1.5% to 0.8%
AORN Journal j 79.e2
n Patients included a range of economic Seattle, Washington) n Decline in inpatient complications, from
www.aornjournal.org
groups and populations n Carried out from October 2007 to 11.0% to 7.0%
n 3,733 patients met the inclusion criteria September 2008
before implementation of the Surgical
Safety Checklist
n 3,955 patients met the inclusion criteria
after checklist implementation
(table continued)
July 2014 Vol 100

Evidence
The Joint Commission n Regulatory agency recommendation to n The patient has a role in communications IV B
(2012)7 designate the patient as an active par- related to site verification, patient identi-
No 1
ticipant in some safety checks associ- fication, verification of the procedure

ated with the surgical safety checklist being performed, and confirmation of
any allergies
n The patient is a stakeholder
Lingard et al (2008)8 n 13-month quasi-experimental study to n Nonprobability purposive sample of n Showed support for the hypothesis that II A
examine whether implementation of a general surgeons, surgical residents, OR a surgical safety checklist combined with
surgical safety checklist accompanied by nurses, anesthesia professionals, and surgical team briefings reduces the
structured OR briefings affected team anesthesia professional residents at an number of communication failures and
communications and, more specifically, academic tertiary center in Canada promotes team communication
whether it reduced communication n Offered evidence of a causal relationship
failures between communication and safety
n Prospective design with a pre-post n Decline in communication failures from a
intervention survey tool and thorough mean of 3.95 (SD 3.20) to 1.31 (SD 1.53)
observation of 172 procedures per surgical procedure after the inter-
vention (P < .001)
Makary et al (2007)9 n 5-month nonexperimental study to n Survey with high response rate was n Supported the hypothesis that surgical III B
investigate OR briefings conducted in sought; no sampling teams with higher levels of communica-
conjunction with the surgical safety n Conducted at a large academic medical tion and collaboration have a decreased
checklist and their effect on com- center in Baltimore, Maryland risk of wrong-site surgery
munications n Showed briefings reduced the risk of
n Pre-post design for which a survey was wrong-site surgery and improved
administered before and after introduc- collaboration among the team (F [6,390]
tion and initiation of OR briefings in ¼ 10.15, P < .001), as reported by
combination with the use of a surgical surveyed health care professionals
safety checklist n 11 surgeons implemented the briefings
after 2 months of collecting baseline data
COLLINS ET AL
Panesar et al (2011)10 n Retrospective study of orthopedic pro- n Stratified sample from a database (ie, n Suggested that more than 20% of III B
cedures to identify patient safety issues The National Reporting and Learning wrong-site surgeries could have been
(eg, wrong-site surgery) Service) prevented through the use of the surgical
safety checklist
SURGICAL CHECKLISTS AND ERRORS
Evidence
n Reviewed data from hospitals in the
United Kingdom for procedures per-
formed in 2008
n 316 procedures met the inclusion criteria
Patient Safety First n The National Patient Safety Agency sur- n Nonprobability purposive sample n Respondents indicated that factors most IV B
(2012)11 veyed 167 acute care hospitals to verify n Total respondents ¼ 161 important to successful implementation
their fulfillment of the requirements of the n Conducted in England and Wales were having a clinical champion (76%),
WHO Surgical Safety Checklist nursing staff support (75%), and clini-
cians as key stakeholders (62%)
Sewell et al (2011)12 n Quasi-experimental study to examine the n Nonprobability convenience sample n Before the educational intervention, the II A
relationship among the surgical checklist, n Conducted at a single-site hospital in the researchers found proper use of the
team communications, and teamwork United States surgical safety checklist 7.9% of the
n Prospective audit of checklist use in time; after the intervention, they found
elective and emergent orthopedic pro- proper use 96.9% of the time
cedures before and after an intervention n 76% of personnel thought the sur-
at a single-site hospital gical safety checklist improved team
n Data collected on 480 patients before an communications
educational intervention and on 485 pa-
tients after the intervention
n Educational program designed to pro-
mote the use of a surgical safety
checklist
Sivathasan et al n Telephone survey of 421 private and n Nonprobability convenience sample n Because of time pressures in the OR, III B
(2010)13 public hospitals to determine whether n Surveyed 421 private and public hospi- personnel may have omitted certain
ORs were using the WHO Surgical tals in the United Kingdom tasks on the surgical safety checklist,
Safety Checklist sometimes leading to an error
n Conducted before compulsory imple- n Only two-thirds of respondents reported
mentation of the WHO Surgical Safety their hospital uses the surgical safety
AORN Journal j 79.e4
www.aornjournal.org
Checklist took effect checklist
Takala et al (2011)14 n International, quasi-experimental, 6- n Nonprobability convenience sample of n Most communication failures were ex- II A
week prospective pilot study to investi- volunteer participants perienced by only 1 team member,
gate the effectiveness of the surgical n Conducted at 4 university teaching hos- usually the surgeon
safety checklist pitals in Finland
(table continued)
July 2014 Vol 100

Evidence
n Pre-post intervention design n Decrease in communication failures after
n 1,748 procedures: 901 questionnaires implementation of the surgical safety
No 1
before the use of a surgical safety checklist:

checklist, 847 after n Circulating RNs: from 23% to 3%
(P < .001)
n Anesthesia professionals: from
13% to 6% (P < .05)

n Surgeons: from 9% to 10%
(not significant)
n Increase in the confirmation of the pa-
tient’s identity, from 94.2% to 81.6%
(P < .001)
Vats et al (2010)15 n 6-month, pre-post intervention pilot n Nonprobability convenience sample n Support from stakeholders linked to III B
study of the implementation of an n Observed 729 procedures thorough completion of the surgical
adapted version of the WHO Surgical n Conducted in 2 ORs in 1 hospital in the safety checklist and correct performance
Safety Checklist United Kingdom of the time out
n The range in compliance with the use of
the surgical safety checklist was 42% to
80%
CI ¼ confidence interval; SD ¼ standard deviation.
1. Askarian M, Kouchak F, Palenik CJ. Effect of surgical safety checklists on postoperative morbidity and mortality rates, Shiraz, Faghihy Hospital, a 1-year study. Qual Manag Health Care. 2011;20(4):293-297.
2. Butcher L. Wrong-site surgery. Hosp Health Netw. 2011;85(11):34-37, 1.
3. Conley DM, Singer SJ, Edmondson L, Berry WR, Gawande AA. Effective surgical safety checklist implementation. J Am Coll Surg. 2011;212:873-879.
4. Dellinger EP. Implementation of the surgical care outcomes assessment program (SCOAP) and the introduction of the WHO/SCOAP surgical safety checklist. http://www.saferhealthcarenow.ca/EN/Interventions/
SafeSurgery/Documents/Workshops/Plenary%20SCOAP%20Checklist%20Dr%20Dellinger.pdf. Published 2009. Accessed January 23, 2014.
5. de Vries EN, Prins HA, Crolla RM, et al. Effect of a comprehensive surgical safety system on patient outcomes. N Engl J Med. 2010;363(20):1928-1937.
6. Haynes AB, Weiser TG, Berry WR, et al. A surgical safety checklist to reduce morbidity and mortality in a global population. N Engl J Med. 2009;360(5):491-499.
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Surgical Safety Checklist

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Surgical Safety Checklist

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Effectiveness of the Surgical

Safety Checklist in Correcting

making errors.2 Medical errors place patients at

TABLE 1. Synthesis of Cited Works from the Literature Review

TABLE 1. (continued ) Synthesis of Cited Works from the Literature Review

1. Butcher L. Wrong-site surgery. Hosp Health Netw. 2011;85(11):34-37, 1.

Patient Safety First; 2012:2. http://www.patientsafetyfirst

July 2014 Vol 100

mission Center for Transforming Health- procedures were performed,

surgery centers that performed more n primary documentation was not

prepping or was not visible after

the correct time,

when multiple procedures have

n personnel who are not empowered

high procedure volume and the

n opportunities for feedback, dialogue,

and increased staff member support

July 2014 Vol 100

ticipant in some safety checks associ- ﬁcation, veriﬁcation of the procedure

July 2014 Vol 100

before the use of a surgical safety checklist:

13% to 6% (P < .05)

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