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Medicine has become increasingly complex, and multidisciplinary teams are common, especially in surgery. Within this environment, checklists help clinicians focus on relevant information at the most appropriate time. By understanding the history of surgical checklists and best practices in their implementation, you can better use them as a member of the perioperative team. It is not simply the existence of a checklist nor its declared use within an organization that effects change, but rather actual integration into routine practice. To achieve lasting change, integration requires resources, time, and cultural buy-in.

Equally important to a checklist’s content is its timing. If it is determined that a checklist is a worthwhile intervention, it should be carefully discussed how the checklist will be used and how it may t into existing workows [2]. Typically, checks are performed at natural pauses in a process, to ensure that all relevant materials are acquired, and elements are addressed to allow corrective actions before a non-reversible step forward. Checklists’ progression in an anticipated sequence helps streamline use by ensuring consistency and minimizing disrup­tions, while identifying and correcting errors of omission or commission before consequences to the patient. While some checklists were designed for routine use in all circumstances, others were specically designed for emergencies or uncom­mon situations beyond most people’s familiarity. In the medical context, this ranges from routine pre-procedural time-outs or anesthesia machine set-up to “crisis checklists” which facilitate prompt, coordinated responses to events like venous air embolism, anaphylaxis, cardiac arrest, re, or malignant hyperthermia, among others [5, 6].

In 2001, anesthesiologist and critical care physician Dr. Peter Pronovost introduced a bundle of interventions pertaining to central line management at Johns Hopkins Hospital. These interventions included a checklist to reinforce adherence to infection- control practices during line insertion: handwashing, skin cleaning with chlorhexidine, sterile draping of the patient, wearing sterile equipment, and apply­ing a sterile dressing. An initial study indicated the rate of catheter-related blood stream infections decreased dramatically, preventing multiple deaths and saving their hospital millions of dollars per year [23].

Shortly after the Keystone ICU Project, the Joint Commission took decisive action to broadly implement checklists for tackling widespread surgical errors head-on. As such, by July 2004, all accredited organizations had to adhere to a “Universal Protocol for Preventing Wrong Site, Wrong Procedure, Wrong Person Surgery” [26]. This protocol involved verifying the patient, marking the surgical site, and performing a time-out before the procedure begins. While it is unclear whether the Universal Protocol achieved its goals in reducing the key avoidable surgical errors, it was a profound step toward institutions’ incorporation and habituation of routine safety measures [15].

Also in 2003, while the Keystone ICU Project was happening in the US, a team from Canada developed and implemented a checklist focused on surgical teams and their communication [27]. Using a vascular surgery team as their participants, the researchers found that key communication functions were provision of adequate case-related information, conrmation of details, articulation of concerns, and team building. Practically speaking, the execution of this checklist took just a few min­utes and, while it caused some inconveniences in terms of altered workow, all participants felt the discussions were efcient. Thus, the Canadian study established that a team checklist could promote information exchange and facilitate team cohesion.

Three years later, in 2006, the Veterans Health Administration (VHA) imple­mented a nationwide Medical Team Training program across more than 100 facili­ties. Following a 2-month preparation phase, training staff worked with implementation teams to assess problem areas and understand local contexts. The actual training session involved a day-long workshop where OR teams were trained

Based on the recognition that many, if not most, surgical errors occur outside the OR, the Surgical Patient Safety System (SURPASS) checklist was developed by a group of medical centers in the Netherlands to address the full scope of surgical patients’ care from admission to discharge. Beyond participation from the surgeon, anesthesiologist, and operating assistant, the SURPASS checklist involves partici­pation of the ward doctor and nurse with added components like hand-off of post­operative instructions and medication provision at discharge. While most surgical checklists’ items take place within the OR, SURPASS contains 124 items collected across six time points and multiple potential locations.

Development of the checklist was guided by three principles: simplicity, wide applicability, and measurability. The content was selected based on a comprehen­sive review of safety practices with known benets to surgical patients, with consid­eration of global settings with various resources [21]. In terms of timing, the team identied three points in the typical surgical workow which were conducive to pauses for conrmation and action if needed: “Sign In” prior to induction of anes­thesia: “Time Out” before skin incision, and “Sign Out” before the patient leaves the OR.The SSC was extensively trialed and iterated, whereby confusing actions and language were claried and rened before being retested in new settings according to the Plan-Do-Study-Act model [21]. Through this iterative, consensus-based pro­cess, the initial standards were translated into a highly useable, one-page, 19-item checklist for use in ORs (Fig.2.1) [33]. To successfully develop a surgical checklist, however, formal testing and evaluation are just as important as the initial creation of content, as will be discussed in subsequent sections.

The rst stage of this work involved a global pilot. Eight international sites evalu­ated the WHO SSC between October 2007 and September 2008. After baseline data collection, local investigators were given information about site deciencies and tasked with implementing the checklist based on an implementation manual that provided adaptable guidance. The implementation process was intensive and included translation into the local language and tailoring of the checklist and its use to t local practices. This process was followed by written and in-person instruction of surgical teams to optimize buy-in and performance. Patients’ death rate decreased from 1.5% to 0.8% following the SSC’s introduction, and inpatient complication rate decreased from 11.0% to 7.0% [34]. It should be noted that while the sites rep­resented a variety of economic circumstances and diverse patient populations, they were specically chosen to maximize the chances of implementation success and were not necessarily representative of typical hospitals.

Shortly after that pilot study, the SSC proliferated. By March 2009, over 1000 hospitals around the world were using it; by January 2010, that number more than tripled [35]. Numerous health agencies endorsed the checklist and facilitated its

implementation in their jurisdictions. In some instances, the SSC was implemented along with a package of other patient safety interventions [36].