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Logo of rjaicRomanian Journal of Anaesthesia and Intensive Care
Rom J Anaesth Intensive Care. 2015 October; 22(2): 111–121.
PMCID: PMC5505371

Language: English | Romanian

A prospective observational assessment of Surgical Safety Checklist use in Brasov Children’s Hospital, barriers to implementation and methods to improve compliance

Utilizarea formularului de verificare a siguranţei în domeniul chirurgical la Spitalul de copii din Braşov, bariere de implementare şi metode de a îmbunătăţi complianţa



The WHO surgical checklist is a universal tool which has been shown to reduce surgical morbidity and mortality and improve patient safety; however, simply implementing a checklist in a hospital may not lead to its utilisation. We aim to evaluate completion of this checklist, and to investigate problems in compliance and methods for improving these.


In July 2015 data was recorded regarding compliance with each of the components of the Surgical Safety Checklist (SSC) in a Children’s Hospital in Brasov. 40 surgeries were observed over 10 days, information was gathered as regards to the surgical speciality, the number of surgeries per day, the number of theatre staff present and whether it was elective or emergency. At the end of the 10 days questionnaires were given to 15 staff members to ask their opinions regarding the surgical checklist. Data analysis was performed using a chi-squared with p < 0.05 determining statistical significance.


None of the checklists in the patient files were filled in; however, components of the SSC were completed, with an average of 55% of the checklist being performed. The percentage of the SSC completed was not statistically significant with different numbers of staff, theatre numbers of the day, speciality and whether it was elective or emergency.


The success of the Surgical Safety Checklist implementation is dependent on the training of staff to improve knowledge and compliance. It cannot be assumed that the introduction of a checklist will automatically lead to improved outcomes and communication with staff is essential in order to improve and ensure compliance.

Keywords: checklist, compliance, paediatric, surgery, Romania, safety



Formularul de verificare al Organizaţiei Mondiale a Sănătăţii pentru siguranţa pacientului, utilizat în cazul intervenţiilor chirurgicale, este un instrument universal care s-a dovedit că ajută la reducerea morbidităţii şi mortalităţii, augmentând siguranţa pacientului; totuşi, simpla implementare a formularului poate să nu însemne implicit utilizarea acestuia în mod curent. Ne-am propus să evaluăm gradul de completare a acestui formular şi să căutăm problemele legate de complianţă în implementare şi de metode de îmbunătăţire a acestora.


În iulie 2015, la Spitalul de copii din Braşov s-a demarat înregistrarea datelor privind complianţa pentru fiecare din componentele formularului de verificare a siguranţei în domeniul chirurgical. Timp de zece zile s-au urmărit 40 de intervenţii chirurgicale, s-au colectat date legate de specialitatea chirurgicală, numărul zilnic de intervenţii chirurgicale, numărul de persoane prezent în sala de operaţie precum şi de tipul intervenţiei: de elecţie sau de urgenţă. La sfârşitul celor 10 zile, prin chestionare adresate către 15 membri din colectivul clinicii, s-au solicitat opinii legate de formularul de verificare. Analiza datelor s-a realizat utilizând testul Chi-patrat, iar un p < 0,05 a fost considerat statistic semnificativ.


Nici un formular de verificare din foile de observaţie ale pacienţilor nu a fost completat în întregime; totuşi, componente din acest formular au fost puse în aplicare în proporţie de 55%. Procentul de completare a formularului nu s-a corelat cu numărul personalului din sala de operaţie, specialitatea chirurgicală, sau cu tipul de intervenţie chirurgicală, de elecţie sau de urgenţă.


Succesul implementării acestui formular depinde de capacitatea personalului de a-şi îmbunătăţi cunoaştinţele şi complianţa. Nu se poate considera că introducerea formularului de verificare va conduce automat la obţinerea de rezultate superioare. Pentru a asigura şi îmbunătăţi complianţa, comunicarea cu personalul este esenţială.


Studies have shown that structured briefings and checklists improve team communication, the sharing of information, decision making and planning [13]. In 2008, the World Health Organization (WHO) published guidelines identifying multiple recommended practices to ensure the safety of surgical patients worldwide. After implementation of the WHO surgical safety checklist (SSC) in eight diverse institutions around the globe, there were statistically significant reductions in the rates of death and complications [4]. The implementation of a modified world health organisation surgical safety checklist has been implemented in locations from Iran [5] to America [6], in paediatric surgery [7] and adult surgery and across specialties [8]. WHO claims it to be universally applicable as the implementation of the checklist is associated with concomitant reductions in the rates of death and complications in a diverse group of hospitals and specialties.

Introduction of the checklist into a hospital is not sufficient to improve outcomes and compliance and understanding of the checklist may be a reason for the variation in the impact in surgical outcomes [912]. Conley et al 2010 investigated the factors influencing implementation of the checklist in five Washington hospitals and concluded that effectiveness was dependent on the ability of leaders to persuasively explain why and adaptively show how to use the checklist [13]. Socioeconomics may also play a part in disparities in compliance, with a comparison of the surgical safety checklist use in high-income and low income families found compliance higher in the high income setting [14].

Following the WHO’s Safe Surgery Saves Lives campaign [15], approximately 1790 institutions worldwide are now reported to be using the checklist [16]. Brasov introduced the checklist in early 2015 with a copy of the Surgical Safety Checklist (SSC) in each of the patient’s notes. Approximately 15 surgeries are performed a day in Brasov split between orthopaedics, general surgery, plastic surgery, ear nose and throat (ENT) and ophthalmology, and each specialty is required to fill in the SSC. As introduction of the checklist on its own is insufficient to improve outcomes, observations of compliance should be done in order to achieve maximum benefit from the checklist.


This paper aimed to observe the implementation of the WHO surgical safety checklist in the Brasov Children’s hospital. Completion of the checklist was recorded and problems in compliance were investigated. Methods for increasing knowledge and adherence of the checklist were explored and suggestions for improvement made.

Study design

40 surgeries were observed over a 10 day period and adherence to the surgical safety checklist (Figure 1) was assessed. The following information was recorded regarding each surgery:

Fig. 1
Surgical Safety Checklist
  • – Was the surgery elective/emergency?
  • – Surgical speciality?
  • – Number of theatre staff?
  • – Number of surgery of the day?

The information gathered was analysed to see if any of these variables had an impact on the completion of the checklist.

At the end of the week 5 nurses, 5 registrars and 5 senior doctors in each location were asked questions regarding their knowledge of the surgical safety checklist, any training they had received and its perceived usefulness. Suggestions for improvement were taken.

All statistical analysis was done using SPSS. Differences in individual variables between two groups (e.g., would a poster improve compliance – YES or NO) were assessed using a one sample t-test. Differences in categorical variables between more than two groups (e.g., specialty) were assessed using one-way ANOVA. The alpha error level was set at 0.05, with p < 0.05 being considered statistically significant.


Over all specialities adherence to the surgical safety checklist in Brasov Romania was poor with 0% of checklists having been completed entirely with an average only 55% of each checklist being completed. The worst performed components of the checklist were that team members introduced themselves and that the surgeon, anaesthesia professional and nurse reviewed the key concerns for recovery and management of the patient. The Sign In component of the checklist was the most commonly performed section, and the time out was the most poorly done section (Figure 2).

Fig. 2
Completion of each component of checklist in all surgeries

Of the surgeries observed 25 were elective and 15 emergency (Figure 3). Adherence to the checklist was higher in emergency surgery compared to elective surgery (Figure 4); however, using ANOVA the results were not significant (F(1, 38) = 0.015, p = 0.902).

Fig. 3
Distribution of surgeries by type
Fig. 4
Mean Percentage of Checklist completed by Type of Surgery

The number of surgeries observed in each specialty varied (Figure 5), as did adherence (Figure 6). Using a one-way-ANOVA, it was found that a significant score was reported referring to the overall speciality of the surgery (orthopaedic, general, plastics, ENT or ophthalmology) and the number of components of the checklist completed (F(4, 35) = 5.356, p = 0.002). A Tukey post-hoc test revealed that the amount of components in the checklist completed was significantly lower for orthopaedic (7.3 ± 2.7) when compared to ENT (11.5 ± 1.8, p = 0.004) and general surgery (11.6 ± 1.8, p = 0.003). All other tests resulted in insignificant results (see Tables for SPSS output in Appendix).

Fig. 5
Distribution of surgeries by speciality
Fig. 6
Mean percentage of checklist completed by speciality

The surgeries observed ranged from being first on the theatre list to fifth (Figure 7). 15 surgeries were first on the list, 13 second, 6 third, 4 fourth and 2 surgeries were fifth. Adherence increased as the position of the surgery on the theatre list increased (Figure 8). However, using ANOVA this increase was found to be statistically insignificant (F(4, 35) = 0.669, p = 0.618).

Fig. 7
Distribution of surgeries by position on theatre list
Fig. 8
Mean Percentage of checklist completed by position of surgery on theatre list

The number of staff in the theatre ranged from four to nine (Figure 9), and although adherence varied (Figure 10) there was no statistical significance (F(5, 34) = 0.777, p = 0.573) between adherence to the checklist and the number of staff in the theatre.

Fig. 9
Distribution of surgeries by number of staff in theatre
Fig. 10
Mean Percentage of Checklist completed and number of staff in theatre

When responding to the questionnaires 80% of staff were aware of the checklists’ existence although only 40% claim to having received training on its use. Awareness of training was surprisingly more common in nurses than in registrar doctors and senior doctors. 93% of staff felt that the checklist was a useful tool, and 7% were undecided.

When staff members were asked what courses of action would improve knowledge of the checklist; formal training (T (14) = 4.58, p < 0.001) and presentations (T (14) = 3.50 p < 0.004) received significantly positive scores when calculated via a one sample t-test (Figure 11). Although three staff members felt that Posters would be useful, and the same number felt leaflets would be useful, the results were found to be insignificant T (14) = 1.87, p < 0.082.

Fig. 11
Staff answers for questionnaires regarding methods to improve knowledge of the surgical safety checklist

When staff members were asked about what courses of action would improve compliance to the surgical checklist; formal training (T (14) = 2.65, p < 0.019), presentations (T (14) = 3.50, p < 0.004), and regular audits (T (14) = 2.646, p < 0.019) were found to be significant using a one sample t-test (Figure 12).

Fig. 12
Staff answers for questionnaires regarding methods to improve compliance of the surgical safety checklist

The majority of staff felt that both lack of awareness and lack of time contributed to the surgical safety checklist not being implemented; one senior doctor felt that neither was the reason and marked other. On questioning he said he felt that it was lack of motivation on behalf of the staff (Figure 13).

Fig. 13
Staff answers to questionnaires regarding reason for lack of adherence


A wide range in compliance rates for surgical checklists can be found in previous studies, ranging from 12% to 100% with a mean of 75% [17]. In this study no surgical safety checklists were completed in the patient file, and no surgery had all of the components of the checklist completed with an overall mean percentage of 55% of the checklist being performed. Several components of the checklist were undertaken and verbalised; however, there was a lack of coherence and formality. Poor communication has been shown to have a negative impact on performance and safety [1820], and a major role of the Surgical Safety Checklist is to improve communication with staff members in the theatre. Despite compliance of the checklist in this hospital being inconsistent and incomplete, staff responses to the questionnaires suggested a good awareness of the SSC, and all of the staff felt that formal training would be beneficial.

This study found that adherence varied depending on specialty in accordance with other studies. However, our study showed Orthopaedic staff completed less components of the checklist than General and ENT, whilst previous studies have found General Surgery to have lower compliance [21]. The most poorly performed component of the Surgical Safety Checklist was Staff introductions which was never done, and a reason for this may be because it is a small hospital where all of the staff know each other and they may find this step redundant.

During the study there was one consultant who felt it was neither lack of time nor knowledge which was the reason for non-compliance, but lack of motivation. It has been shown that team leaders promote learning in a theatre environment [22] and that implementation of patient safety tools is dependent on facility leadership support [23]. A method to foster an attitude of team leadership and increase motivation within staff may be to give registrars responsibility for the completion of the surgical safety checklist during their surgeries. This may provide the leaders necessary to improve implementation, and any failings can be seen through audit. Leadership has been shown to improve learning in MDTs [22] and so by encouraging the registrars to become leaders within the surgical speciality, it could impact other aspects of patient care. Previous studies have highlighted that in order for compliance to increase active participation, training is needed by theatre staff [17], and so recommendations by staff regarding training should be taken on board. Conley 2011 found that efforts to explain why the checklist is being implemented and extensive education regarding its use resulted in buy-in among surgical staff and thorough checklist use [13]. Our study supported this as the staff felt that presentations on the checklist would be a useful method of improving knowledge of the checklist and also compliance. These presentations can be used to promote the benefits of the checklist and provide evidence supporting its application.

As a result of this report, actions suggested include posters of the Surgical Checklist being placed in each theatre, and a presentation being given to staff at a morning briefing later this month, the content of which will be put into a leaflet. To ensure the training is formal a register of the staff who will attend the presentation will be taken. The use of the checklist will be audited in 3 months and the results used to determine the success of these changes.

Limitations of the study include that it only included 40 operations being observed and the value of the results of the questionnaire are limited as 15 is a small number staff to ask. Despite the small number of staff questioned, the similarity in the results gathered do support that conclusions gathered were accurate. This study is also limited in that it did not look at patient outcomes to assess whether completion of the checklist had any effect, although many other studies do this [6, 24], including in low income settings [12]. Another drawback of this study is we did not ask which form of formal training staff members had underwent, which if we had done, we would have been able to assess its effectiveness. Further limitations include that individuals knew I was monitoring the use of the checklist and so this may have caused a Hawthorne effect. A potential selection bias can be found in the selection of surgical procedures as surgeries were observed depending on the start time in order to see a large selection of different surgeries. In addition, a conscious effort was made to see different specialties and surgical teams in order to limit potential selection bias.


The success of the surgical checklist implementation is dependent on training of staff to improve knowledge and compliance. It cannot be assumed that the introduction of a checklist will automatically lead to improved outcomes and communication with staff is essential in order to improve and ensure compliance.


Table 1

Type of surgery and number of components completed

number of components completed

Sum of SquaresdfMean SquareFSig.
Between groups.1071.107.015.902
Within groups263.493386.934

Table 2

Mean scores of speciality and number of components completed

number of components completed

Speciality of surgeryMeanNStd. deviation

Table 3

Post-hoc test of specialty and number of components completed

Multiple Comparisons
Dependent variable: number of components completed

(I) speciality of surgery(J) speciality of surgeryMean difference (I–J)Std. errorSig.95% Confidence interval

Lower boundUpper bound
Tukey HSDopthalmologyplastics.1251.7091.000−4.795.04









*The mean difference is significant at the 0.05 level

Table 4

Post hoc of surgery position and components of checklist completed

Multiple Comparisons
Dependent variable: number of components completed

(I) number of surgery that day(J) number of surgery that dayMean difference (I–J)Std. errorSig.95% Confidence interval

Lower boundUpper bound
Tukey HSD12−.3641.002.996−3.252.52










Table 5

ANOVA of speciality and number of components completed

number of components completed

Sum of SquaresdfMean SquareFSig.
Between groups100.087425.0225.356.002
Within groups163.513354.672

Table 6

Surgery position and components of checklist completed

number of components completed

Sum of SquaresdfMean SquareFSig.
Between groups18.72644.681.669.618
Within groups244.874356.996

Table 7

Number of staff in surgery and components of checklist completed

number of components completed

Sum of SquaresdfMean SquareFSig.
Between groups27.04455.409.777.573
Within groups236.556346.958


Conflict of interest

Nothing to declare


There was no grant support towards this research


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