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CONTINUING EDUCATION

Back to Basics:Implementing the SurgicalChecklistLISA SPRUCE, DNP, RN, ACNS, ACNP, ANP, CNOR 1.7

www.aorn.org/CE

Continuing Education Contact Hoursindicates that continuing education (CE) contact hours

are available for this activity. Earn the CE contact hours by

reading this article, reviewing the purpose/goal and objec-

tives, and completing the online Examination and Learner

Evaluation at http://www.aorn.org/CE. Each applicant who

successfully completes this program can immediately print

a certificate of completion.

Event: #14542

Session: #0001

Fee: Members $13.60, Nonmembers $27.20

The CE contact hours for this article expire November 30,

2017. Pricing is subject to change.

Purpose/GoalTo provide the learner with knowledge of best practices related

to implementing a surgical checklist.

Objectives

1. Discuss common areas of concern that relate to periop-

erative best practices.

2. Discuss best practices that could enhance safety in the

perioperative area.

3. Describe implementation of evidence-based practice in

relation to perioperative nursing care.

AccreditationAORN is accredited as a provider of continuing nursing

education by the American Nurses Credentialing Center’s

Commission on Accreditation.

ApprovalsThis program meets criteria for CNOR and CRNFA recertifi-

cation, as well as other CE requirements.

AORN is provider-approved by the California Board of

Registered Nursing, Provider Number CEP 13019. Check with

your state board of nursing for acceptance of this activity for

relicensure.

Conflict of Interest DisclosuresLisa Spruce, DNP, RN, ACNS, ACNP, ANP, CNOR, has

no declared affiliation that could be perceived as posing

a potential conflict of interest in the publication of this

article.

The behavioral objectives for this program were created

by Helen Starbuck Pashley, MA, BSN, CNOR, clinical

editor, with consultation from Susan Bakewell, MS, RN-BC,

director, Perioperative Education. Ms Starbuck Pashley and

Ms Bakewell have no declared affiliations that could be

perceived as posing potential conflicts of interest in the pub-

lication of this article.

Sponsorship or Commercial SupportNo sponsorship or commercial support was received for this

article.

DisclaimerAORN recognizes these activities as CE for RNs. This rec-

ognition does not imply that AORN or the American Nurses

Credentialing Center approves or endorses products mentioned

in the activity.

http://dx.doi.org/10.1016/j.aorn.2014.06.020

� AORN, Inc, 2014 November 2014 Vol 100 No 5 � AORN Journal j 465

Back to Basics:Implementing the SurgicalChecklistLISA SPRUCE, DNP, RN, ACNS, ACNP, ANP, CNOR 1.7

www.aorn.org/CE

ABSTRACT

Surgery is complex and technically demanding for all team members. Surgical

checklists have been implemented with different degrees of success in the perioper-

ative setting. There is a wealth of evidence that they are effective at preventing patient

safety events and helping team members master the complexities of modern health

care. Implementation is key to successful use of the surgical checklist in all invasive

procedural settings. Key strategies for successful checklist implementation include

establishing a multidisciplinary team to implement the checklist, involving surgeon

leaders, pilot testing the checklist, incorporating feedback from team members to

improve the process, recognizing and addressing barriers to implementation, and of-

fering coaching and continuous feedback to team members who use the checklist.

Using these strategies will give the perioperative nurse, department leaders, and sur-

geons the tools to implement a successful checklist. AORN J 100 (November 2014)

466-473. � AORN, Inc, 2014. http://dx.doi.org/10.1016/j.aorn.2014.06.020

Key words: surgical checklist, time out, surgical errors, preventing surgical error.

In 2009, Atul Gawande, MD, authored The

Checklist Manifesto, a ground-breaking look at

the fact that health care and medicine have be-

come so complex and specialized, they are difficult

for humans to master.1 Every year, 50 million

surgeries are performed, and Gawande points out

that 150,000 patients die each year after undergoing

surgery. This is more than three times the number

of deaths attributed to traffic accidents.1 Many of

these surgical deaths are avoidable and preventable

through the use of the surgical checklist.

We use checklists in everyday life, from a sim-

ple recipe to a grocery list, and we check off

the steps and ingredients to make sure nothing is

forgotten. The professional use of checklists is not

new, but it developed in the aviation industry, not

in health care. In the 1930s, Boeing developed a

pilot’s checklist because new planes, at the time,

were being developed with complicated flight in-

structions that were too complex to be left to pilot

memory.1 The pilots of these new planes went on to

fly 1.8 million times without incident.1 Fast for-

ward to 2014. The surgical checklist has been in

use in almost every OR throughout the United

States and the world. Surgical checklists have

been created by The Joint Commission,2 the

World Health Organization3 (WHO) (Figure 1), the

Surgical Patient Safety System (SURPASS),4 and

http://dx.doi.org/10.1016/j.aorn.2014.06.020

466 j AORN Journal � November 2014 Vol 100 No 5 � AORN, Inc, 2014

Figure

1.TheWHO

SurgicalSafety

Checklist.Reprintedwithperm

issionfrom

theWorldHealthOrganization,Geneva,Switze

rland.

AORN Journal j 467

BACK TO BASICS: SURGICAL CHECKLIST www.aornjournal.org

AORN (Figure 2).5 The question is, how are they

working?

THE SURGICAL CHECKLIST

In December 2012, Borchard et al6 published a

systematic review that assessed the compliance,

effectiveness, and critical factors needed for im-

plementing surgical checklists. The review included

22 articles that met the study selection criteria.

The collective evidence showed that when a sur-

gical checklist is used, the relative riskdthat is, the

risk of a particular event occurring for different

groups of people7dfor mortality is 0.57 and the

risk of any complication is 0.63. The overall

checklist compliance rate in the review ranged

from 12% to 100%, and time-out compliance rates

were 70% to 100%. The investigators concluded

that checklists were effective and economical tools

to decrease morbidity and mortality in the surgi-

cal setting.6

Researchers in the Netherlands published a

retrospective cohort study in 2012 that analyzed

all adult surgical patients who required hospital

admission at a university medical center.8 The main

purpose of the study was to examine in-hospital

mortality before and after implementation of the

WHO surgical checklist. The researchers measured

crude mortality, which is the number of deaths in a

population during a specific period using the total

population at the midpoint of the period as the

denominator in the calculation, as well as mortality,

which is the overall death rate without consider-

ation of the number of people in the population.

After implementation of the checklist, crude mor-

tality decreased from 3.13% to 2.85%; after adjusting

for baseline differences (eg, patient characteristics,

surgical specialty, comorbidities), the researchers

showed that mortality also was significantly de-

creased (odds ratio, 0.85; 95% confidence inter-

val, 0.73-0.98). The beneficial effects were strongly

related to checklist completion and compliance.

In 2013, Lubbeke et al9 conducted a quasi-

experimental prestudy that looked at measures

used before checklist implementation and a

poststudy to evaluate postimplementation mea-

sures. Both phases of the study evaluated the

effectiveness of an intraoperative checklist in high-

risk surgical patients. The environment of this

study had a high standard of surgical care with

regular, long-held perioperative patient safety pro-

grams. The researchers measured unplanned returns

to the OR for any reason, unplanned admission to

an intensive care unit (ICU), reoperation for sur-

gical site infection (SSI), and in-hospital deaths

within 30 days of surgery. They included a total of

2,427 surgical interventions: 609 performed before

and 1,818 performed after implementation of

a checklist.

When comparing preimplementation and post-

implementation data, researchers noted that

there were

n 45/609 (7.4%) unplanned returns to the OR

within 30 days versus 109/1,818 (6.0%),

n 18/609 (3.0%) reoperations for SSI versus

30/1,818 (1.7%),

n 17/609 (2.8%) unplanned admissions to the

ICU versus 48/1,818 (2.6%), and

n 26/609 (4.3%) in-hospital deaths versus

108/1,818 (5.9%).

The investigators concluded that there was a trend

toward a reduction of reoperations for SSI, but they

noted no other checklist influence.9

Treadwell et al10 conducted a systematic review

of the literature in 2014 and looked for studies

that described use of the WHO checklist, the

SURPASS checklist, any wrong-site surgery

checklist, or an anesthesia checklist. They included

33 studies that obtained a variety of outcomes.

They found that safety checklists have been

implemented in a wide variety of settings. The re-

view demonstrated that surgical safety checklists

are associated with a decrease in surgical com-

plications, an increase in detecting potential safety

hazards, and an improvement in communication

among team members.10

468 j AORN Journal

November 2014 Vol 100 No 5 SPRUCE

Figure

2.TheAORN

ComprehensiveSurgicalChecklist.Reprintedwithperm

issionfrom

AORN,Inc.Copyrightª

2014.Allrights

reserved.

AORN Journal j 469


A 2014 Canadian study conducted by Urbach

et al11 had a different conclusion. The investigators

surveyed all acute care hospitals in Ontario to

determine whether a surgical safety checklist had

been implemented and looked at data before and

after checklist implementation. The investigators

compared surgical mortality, rate of surgical com-

plications, length of hospital stay, and rates of

hospital readmission and emergency department

visits within 30 days after discharge in a variety

of surgical patients and concluded that there was

no significant reduction in mortality or surgical

complications when a surgical checklist was

implemented.11

All but one of these studies suggested that

implementation of a surgical safety checklist is

beneficial in improving surgical outcomes, mor-

tality rates, and complications. With regard to the

study by Urbach et al,11 Lucian Leape, MD, stated

that “it is not the act of ticking off a checklist

that reduces complications, but performance

of the actions it calls for.”12(p1063) That is, the

checklist is a tool, but patient safety depends on

team interaction and team communication. Team

members must introduce themselves and have

a discussion about critical surgical steps and

concerns of team members. Dr Leape hypothesized

that the reason for the failure of the surgical

checklist in the Ontario study was that “it was not

actually used.”12(p1064)

In 2011, Conley et al13 conducted a survey

of surgical checklist implementation in five

Washington state hospitals and found that a

key component of successful implementation

was explaining the rationale behind use of a

checklist and adequately demonstrating its use.

HOW-TO GUIDE

Checklists have been proven to be effective in

many situationsdfrom flying an airplane to using

a recipe in the kitchen to performing a surgical

time out. The fact remains, however, that full imple-

mentation may not be occurring. Many perioperative

nurses struggle to get buy-in and compliance from

other perioperative team members and become

frustrated when efforts to complete the checklist

are thwarted.

Conley et al13 suggest taking the following steps

to implement a checklist in the surgical setting:

n Begin implementation by forming a multidis-

ciplinary team led by surgeons and nursing

leaders.

n Obtain buy-in from senior facility leaders.

n Arrange for the multidisciplinary team to

meet two or three times per week to plan and

strategize.

n Have surgeon leaders head the initiative be-

cause perioperative team members will listen

to known surgeon leaders more readily than

leaders whom they do not know well.

n Conduct informal surgeon-to-surgeon conver-

sations surrounding checklist implementation.

n Use one surgeon or one service line to pilot test

the checklist process and make changes based

on feedback.

n Form a surgical checklist implementation

team for every surgical discipline and provide

extensive training to all perioperative team

members.

n Offer real-time coaching to assist surgeons

and other team members with using the

checklist.

n Have champions of the checklist who observe

the process offer continuous feedback to all

perioperative team members.

n Welcome and respond to all staff member

input.

n Recognize and address barriers to implementation,

such as requiring all team members’ signatures on

the checklist. Instead, only require the RN circu-

lator to affirm the checklist was completed.

BENEFITS

The effect of surgical checklists on patients and

their safety has been demonstrated in many

470 j AORN Journal


studies.6,8-10,13 The true effect on patient safety is

based on whether the checklist is performed and

how effectively team members implement it. Safer

care can only be achieved if perioperative team

members recognize the importance of working as

a team, using effective team communication, and

using the checklist as a tool to bring the team

together in a true patient safety effort. Figure 3

provides an illustration of some of the reasons

that team members fail to conduct a checklist

correctly.

STRATEGIES FOR SUCCESS

Although the value of a checklist may be under-

stood, there are ways to help ensure successful

implementation. Some of the following ideas can

be used to successfully implement a checklist in the

surgical setting.

n Make implementation easy by providing a

laminated checklist, a checklist board, or an

electronic checklist that all team members can

see easily.

Figure 3. This What’s Wrong with This Picture? illustration suggests some of the reasons that checklists fail toprevent surgical errors.

AORN Journal j 471


n Have team members introduce themselves be-

fore every procedure and ensure that everyone

in the room is introduced, including students.

n Ensure that surgeons have an active role in the

checklist process by asking them to be leaders

of the process.

n Ask all team members to stop and listen to the

surgeon or RN circulator who is conducting the

checklist and emphasize that all team mem-

bers should agree on the information before

proceeding.

n If any team member looks as if they are unsure,

ask questions to find out why.

n Encourage surgeons to take five minutes at the

beginning of the day to go over the day’s

procedures with the other team members to

anticipate any problems or issues that could

arise.

n Read from the checklist every timeddo not rely

on memory.

n Make sure leaders understand

n the research supporting checklist imple-

mentation,

n facility values that align with checklist

implementation,

n how to build on past successes with patient

safety projects, and

n they must obtain multidisciplinary

involvement.

n Help ensure that perioperative team members

n understand the rationale for checklist

implementation,

n understand ongoing

patient safety efforts,

n recognize their role in

patient safety, and

n value multidisciplinary

involvement.

WRAP-UP

The evidence supports sur-

gical safety checklist use in

the perioperative setting to

help decrease the risk of a

patient safety event and to

anticipate potential patient

issues postoperatively.6,8-13

The key is proper use and

actually completing the

checklist steps. This “Back

to Basics” article provides

key strategies that can be

used to implement a check-

list and some strategies for

success. Using these strate-

gies will give perioperative

nurses, leaders, surgeons,

and other team members

the tools to successfully

Resources for Surgical Checklist Implementation

Web sites

n AORN Comprehensive Surgical Checklist. AORN, Inc. http://

www.aorn.org/Clinical_Practice/ToolKits/Correct_Site_Surgery_

Tool_Kit/Comprehensive_checklist.aspx.

n Patient Safety Tool: SURPASS Checklist. Becker’s Infection

and Quality Control. http://www.surpass-checklist.nl/dlChecklist

.jsf;jsessionid¼0FEB76A00DA444AA208CACA34C07F0E1?

pageId¼Download&lang¼en.

n WHO Surgical Safety Checklist Implementation Guide. World

Health Organization. http://www.who.int/patientsafety/safesurgery/

checklist_implementation/en/.

n WHO Surgical Safety Checklist. World Health Organization

(WHO). http://www.who.int/patientsafety/safesurgery/

checklist/en/.

Videos

n Harvard team using the WHO Surgical Safety Checklist. Lifebox

Foundation. https://www.youtube.com/watch?v¼wgqIkhkXYMQ.

n How not to perform the WHO Safe Surgery Checklist.

WHOSurgeryChecklist. https://www.youtube.com/watch?

v¼DOGJMOMHDJk.

n WHO surgery saves lives checklist. WHOSurgeryChecklist.

https://www.youtube.com/watch?v¼CIFhLUiT8H0.

Web access verified June 11, 2014.

472 j AORN Journal


implement a checklist that can help improve pa-

tient safety.

References1. Gawande A. The Checklist Manifesto. New York, NY:

Metropolitan Books, Henry Holt and Company, LLC;

2009.

2. Safe Surgery Checklist. The Joint Commission. http://

www.jointcommission.org/safe_surgery_checklist/. Ac-

cessed June 11, 2014.

3. WHO Surgical Safety Checklist. World Health Organi-

zation. http://www.who.int/patientsafety/safesurgery/

checklist/en/. Accessed June 11, 2014.

4. Patient Safety Tool: SURPASS Checklist. Becker’s In-

fection and Quality Control. http://www.surpass-check

list.nl/dlChecklist.jsf;jsessionid¼0FEB76A00DA444AA

208CACA34C07F0E1?pageId¼Download&lang¼en.

Accessed June 11, 2014.

5. AORN Comprehensive Surgical Checklist. AORN, Inc.

http://www.aorn.org/Clinical_Practice/ToolKits/Correct_

Site_Surgery_Tool_Kit/Comprehensive_checklist.aspx.

Accessed June 11, 2014.

6. Borchard A, Schwappach DL, Barbir A, Bezzola P.

A systematic review of the effectiveness, compliance,

and critical factors for implementation of safety check-

lists in surgery. Ann Surg. 2012;256(6):925-933.

7. Glossary of terms. Relative risk. Agency for Healthcare

Research and Quality. http://effectivehealthcare.ahrq

.gov/index.cfm/glossary-of-terms/?pageaction¼show

term&termid¼57. Accessed July 16, 2014.

8. Klei WA, Hoff RG, van Aarnhem EE, et al. Effects of

the introduction of the WHO “Surgical Safety Checklist”

on in-hospital mortality. Ann Surg. 2012;255(1):44-49.

9. Lubbeke A, Hovaguimian F, Wickboldt N, et al. Effec-

tiveness of the Surgical Safety Checklist in a high stan-

dard care environment. Med Care. 2013;51(5):425-429.

10. Treadwell JR, Lucas S, Tsou AY. Surgical checklists:

a systematic review of impacts and implementation.

Br Med J. 2014;23(4):299-318.

11. Urbach D, Govindarajan A, Saskin R, Wilton A, Baxter N.

Introduction of surgical safety checklists in Ontario,

Canada. N Engl J Med. 2014;370(11):1029-1038.

12. Leape LL. The checklist conundrum. N Engl J Med.

2014;370(11):11.

13. Conley D, Singer S, Edmondson L, Berry W,

Gawande A. Effective surgical safety checklist imple-

mentation. J Am Coll Surg. 2011;212(5):873-879.

Lisa Spruce, DNP, RN, ACNS, ACNP, ANP,

CNOR, is the director, evidence-based peri-

operative practice, AORN, Inc, Denver, CO.

Dr Spruce has no declared affiliation that could

be perceived as posing a potential conflict of

interest in the publication of this article.

Check back in January 2015 for the next “Back to Basics” topic: Evidence-Based Practice.

AORN Journal j 473


EXAMINATIONCONTINUING EDUCATION

1.7www.aorn.org/CEBack to Basics: Implementing the

Surgical Checklist

PURPOSE/GOAL

To provide the learner with knowledge of best practices related to implementing a

surgical checklist.

OBJECTIVES

1. Discuss common areas of concern that relate to perioperative best practices.

2. Discuss best practices that could enhance safety in the perioperative area.

3. Describe implementation of evidence-based practice in relation to perioperative

nursing care.

The Examination and Learner Evaluation are printed here for your conve-

nience. To receive continuing education credit, you must complete the online

Examination and Learner Evaluation at http://www.aorn.org/CE.

QUESTIONS

1. According to The Checklist Manifesto, 50 million

surgeries are performed and _____ patients die

after surgery every year.

a. 75,000 b. 100,000

c. 150,000 d. 250,000

2. All but one of the studies reviewed in this article

suggest that implementation of a surgical safety

checklist is beneficial in improving surgical out-

comes, mortality rates, and complications.

a. true b. false

3. To successfully implement a checklist in the sur-

gical setting, Conley et al suggest

1. beginning implementation by forming a

multidisciplinary team led by surgeons and

nursing leaders and obtaining buy-in from

senior facility leaders.

2. conducting informal surgeon-to-surgeon

conversations surrounding checklist imple-

mentation and using one surgeon or one

service line to pilot test the checklist

process and make changes based on

feedback.

3. having champions of the checklist who

observe the process offer continuous feed-

back to all perioperative team members.

4. offering real-time coaching to assist sur-

geons and other team members with using

the checklist.

5. recognizing and addressing barriers to

implementation, such as requiring all

team members’ signatures on the

checklist.

a. 2 and 4 b. 1, 3, and 5

c. 2, 3, 4, and 5 d. 1, 2, 3, 4, and 5


4. Strategies for successfully implementing a surgical

checklist include

1. providing a laminated checklist, a checklist

board, or an electronic checklist that all team

members can see easily.

2. having all team members, including stu-

dents, introduce themselves before every

procedure.

3. ensuring that surgeons have an active role in

the checklist process by asking them to be

leaders of the process.

4. asking all team members to stop and listen

to the surgeon or RN circulator who is con-

ducting the checklist and ensuring all agree

on the information before proceeding.

5. asking questions if any team member looks unsure.

6. reading from the checklist every time instead

of relying on memory.

a. 1, 3, and 5 b. 2, 4, and 6

c. 2, 3, 5, and 6 d. 1, 2, 3, 4, 5, and 6

5. The keys to successfully using a surgical safety

checklist are

1. using the checklist properly.

2. using colors to highlight the most important

areas on the checklist.

3. actually completing the checklist steps.

4. forcing surgeons to use checklists.

a. 1 and 2 b. 1 and 3

c. 2 and 4 d. 3 and 4

AORN Journal j 475

CE EXAMINATION www.aornjournal.org

LEARNER EVALUATIONCONTINUING EDUCATION PROGRAM

1.7www.aorn.org/CEBack to Basics: Implementing the

Surgical Checklist

This evaluation is used to determine the extent to

which this continuing education program met

your learning needs. The evaluation is printed

here for your convenience. To receive continuing

education credit, you must complete the online

Examination and Learner Evaluation at http://www.aorn.org/CE. Rate the items as described below.

OBJECTIVES

To what extent were the following objectives of this

continuing education program achieved?

1. Discuss common areas of concern that relate to

perioperative best practices.

Low 1. 2. 3. 4. 5. High

2. Discuss best practices that could enhance safety in

the perioperative area.

Low 1. 2. 3. 4. 5. High

3. Describe implementation of evidence-based practice

in relation to perioperative nursing care.

Low 1. 2. 3. 4. 5. High

CONTENT

4. To what extent did this article increase your

knowledge of the subject matter?

Low 1. 2. 3. 4. 5. High

5. To what extent were your individual objectives met?

Low 1. 2. 3. 4. 5. High

6. Will you be able to use the information from this

article in your work setting? 1. Yes 2. No

7. Will you change your practice as a result of reading

this article? (If yes, answer question #7A. If no,

answer question #7B.)

7A. How will you change your practice? (Select all that

apply)

1. I will provide education to my team regarding

why change is needed.

2. I will work with management to change/

implement a policy and procedure.

3. I will plan an informational meeting with

physicians to seek their input and acceptance

of the need for change.

4. I will implement change and evaluate the

effect of the change at regular intervals until

the change is incorporated as best practice.

5. Other: ________________________________

7B. If you will not change your practice as a result of

reading this article, why? (Select all that apply)

1. The content of the article is not relevant to

my practice.

2. I do not have enough time to teach others

about the purpose of the needed change.

3. I do not have management support to make

a change.

4. Other: ________________________________

8. Our accrediting body requires that we verify

the time you needed to complete the 1.7 con-

tinuing education contact hour (102-minute)

program: _______________________________


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