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Do Safety Checklists Improve Teamwork and Communication in the Operating Room? A Systematic Review

Russ, Stephanie PhD; Rout, Shantanu MRCS; Sevdalis, Nick PhD; Moorthy, Krishna MD, FRCS; Darzi, Ara MD, FRCS, FACS; Vincent, Charles PhD

doi: 10.1097/SLA.0000000000000206

Objectives: The aim of this systematic review was to assess the impact of surgical safety checklists on the quality of teamwork and communication in the operating room (OR).

Background: Safety checklists have been shown to impact positively on patient morbidity and mortality following surgery, but it is unclear whether this clinical improvement is related to an improvement in OR teamwork and communication.

Methods: A systematic search strategy of MEDLINE, EMBASE, PsycINFO, Google Scholar, and the Cochrane Database for Systematic Reviews was undertaken to obtain relevant articles. After de-duplication and the addition of limits, 315 articles were screened for inclusion by 2 researchers and all articles meeting a set of prespecified inclusion criteria were retained. Information regarding the type of checklist, study design, assessment tools used, outcomes, and study limitations was extracted.

Results: Twenty articles formed the basis of this systematic review. All articles described an empirical study relating to a case-specific safety checklist for surgery as the primary intervention, with some measure of change/improvement in teamwork and/or communication relating to its use. The methods for assessing teamwork and communication varied greatly, including surveys, observations, interviews, and 360° assessments. The evidence suggests that safety checklists improve the perceived quality of OR teamwork and communication and reduce observable errors relating to poor team skills. This is likely to function through establishing an open platform for communication at the start of a procedure: encouraging the sharing of critical case-related information, promoting team coordination and decision making, flagging knowledge gaps, and enhancing team cohesion. However, the evidence would also suggest that when used suboptimally or when individuals have not bought in to the process, checklists may conversely have a negative impact on the function of the team.

Conclusions: Safety checklists are beneficial for OR teamwork and communication and this may be one mechanism through which patient outcomes are improved. Future research should aim to further elucidate the relationship between how safety checklists are used and team skills in the OR using more consistent methodological approaches and utilizing validated measures of teamwork such that best practice guidelines can be established.

One mechanism through which safety checklists are designed to positively impact upon patient outcomes in the operating room (OR) is through fostering better interprofessional teamwork and communication. The current systematic review supports that safety checklists do indeed improve these team skills; however, when used suboptimally, or when not all team members are engaged in the process, checklists may have paradoxically adverse effects on team performance. Engaging OR staff in the design, implementation, and customization of safety checklists is important for gaining maximum benefit from their use.

Department of Surgery and Cancer, Imperial College London, London, United Kingdom.

Reprints: Stephanie Russ, PhD, Department of Surgery & Cancer, Imperial College London, Room 504, 5th floor, Wright Fleming Building, Norfolk Place, London W2 1PG, UK. E-mail:

All authors are affiliated with the Imperial College Centre for Patient Safety and Service Quality (, which is funded by the National Institute for Health Research, UK.

Disclosure: The authors declare no conflicts of interest.

© 2013 by Lippincott Williams & Wilkins.