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Surgical Checklist Implementation Project: The Impact of Variable WHO Checklist Compliance on Risk-adjusted Clinical Outcomes After National ImplementationA Longitudinal Study

Mayer, Erik K. PhD, FRCS; Sevdalis, Nick PhD; Rout, Shantanu MRCS; Caris, Jochem MRCS; Russ, Stephanie PhD; Mansell, Jenny MSc, BSc; Davies, Rachel BA (Hons); Skapinakis, Petros PhD, MPH; Vincent, Charles PhD; Athanasiou, Thanos PhD, FETCS; Moorthy, Krishna PhD, FRCS; Darzi, Ara FACS, FMedSci, FRS, KBE

doi: 10.1097/SLA.0000000000001185

Objective: To evaluate impact of WHO checklist compliance on risk-adjusted clinical outcomes, including the influence of checklist components (Sign-in, Time-out, Sign-out) on outcomes.

Background: There remain unanswered questions surrounding surgical checklists as a quality and safety tool, such as the impact in cases of differing complexity and the extent of checklist implementation.

Methods: Data were collected from surgical admissions (6714 patients) from March 2010 to June 2011 at 5 academic and community hospitals. The primary endpoint was any complication, including mortality, occurring before hospital discharge. Checklist usage was recorded as checklist completed in full/partly. Multilevel modeling was performed to investigate the association between complications/mortality and checklist completion.

Results: Significant variability in checklist usage was found: although at least 1 of the 3 components was completed in 96.7% of cases, the entire checklist was only completed in 62.1% of cases. Checklist completion did not affect mortality reduction, but significantly lowered risk of postoperative complication (16.9% vs. 11.2%), and was largely noticed when all 3 components of the checklist had been completed (odds ratio = 0.57, 95% confidence interval: 0.37–0.87, P < 0.01). Calculated population-attributable fractions showed that 14% (95% confidence interval: 7%-21%) of the complications could be prevented if full completion of the checklist was implemented.

Conclusions: Checklist implementation was associated with reduced case-mix-adjusted complications after surgery and was most significant when all 3 components of the checklist were completed. Full, as opposed to partial, checklist completion provides a health policy opportunity to improve checklist impact on surgical safety and quality of care.

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Department of Surgery and Cancer, Imperial College London, London, UK.

Reprints: Erik K. Mayer, PhD, FRCS, Department of Surgery and Cancer, Imperial College, London W2 1NY, UK. E-mail:

Disclosure: This study was funded by the National Institute for Health Research, UK. The authors declare no conflicts of interest.

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