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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

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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.

Background

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

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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?

Literature Review

Methodology

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.

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(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.,

2017).

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

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measure patient mortality, the researchers identified that nurses perceived the WHO SSC

important in order to improve patient safety and outcomes (Penataro-Pintado, 2020).

Sampling

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.

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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).

Research Findings

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.

Study Limitations

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

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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.

Conclusion

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.

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References

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