Multifaceted interventions improve adherence to the surgical checklist

Surgery. 2014 Aug;156(2):336-44. doi: 10.1016/j.surg.2014.03.032. Epub 2014 Jun 16.


Introduction: Adherence to surgical safety checklists remains challenging. Our institution demonstrated acceptable rates of checklist utilization but poor adherence to all checkpoints. We hypothesized that stepwise, multifaceted interventions would improve checklist adherence.

Methods: From 2011 to 2013, adherence to the 14-point, pre-incision checklist was assessed directly by trained observers during three, 1-year periods (baseline, observation #1, and observation #2) during which interventions were implemented. Interventions included safety workshops, customization of a stakeholder-derived checklist, and implementation of a report card system. Chi-square and Kruskal-Wallis tests were utilized.

Results: Checklist performance was assessed for 873 cases (baseline, n = 144; observation #1, n = 373; observation #2, n = 356). Total checkpoint adherence increased (from 30% to 78% to 96%; P < .001), as did cases with correct completion of all checkpoints (from 0% to 19% to 61%; P < .001). The median (interquartile range) number of checkpoints completed per case improved from 4 (3-5) to 11 (10-12) to 14 (13-14; P < .001).

Conclusion: A strategic, multifaceted approach to perioperative safety significantly improved checklist adherence over 2 years. Checklist content and process need to reflect local interests and operative flow to achieve high adherence rates. Successful checklist implementation requires efforts to change the safety culture, stakeholder buy-in, and sustained efforts over time.

Publication types

  • Observational Study

MeSH terms

  • Checklist / standards*
  • Child
  • Education
  • Guideline Adherence / standards
  • Hospitals, Pediatric
  • Humans
  • Medical Errors / prevention & control
  • Operating Rooms / standards
  • Patient Safety / standards*
  • Practice Guidelines as Topic
  • Surgical Procedures, Operative / standards*
  • Texas
  • World Health Organization