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International Journal of Surgery 12 (2014) 2e6

REVIEW

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International Journal of Surgery

journal homepage: www.journal-surgery.net

Review

Surgical safety checklists in developing countries

Sayinthen Vivekananthama,*, Rahul Prashanth Ravindran a, Kumaran Shanmugarajah b,Mahiben Maruthappu b, Joseph Shalhoub a

a Imperial College School of Medicine, Imperial College London, London SW7 2AZ, UKbHarvard University, Cambridge, MA 01451, USA

a r t i c l e i n f o

Article history:Received 29 September 2013Accepted 24 October 2013Available online 13 November 2013

Keywords:SurgerySafetyChecklistsDeveloping countriesWorld Health Organization

* Corresponding author. Tel.: þ44 (0) 798101 5718.E-mail addresses: sayinthen.vivekanantham@gm

rahul.prashanth.ravindran@gmail.com (R.P. Ravindrantbrc.mgh.harvard.edu (K. Shanmugarajah), m(M. Maruthappu), j.shalhoub@imperial.ac.uk (J. Shalh

1743-9191/$ e see front matter � 2013 Surgical Assohttp://dx.doi.org/10.1016/j.ijsu.2013.10.016

a b s t r a c t

The World Health Organization Surgical Safety Checklist (WHO SSC) has demonstrated efficacy indeveloped and developing countries alike. Recent increases in awareness of surgical morbidity indeveloping countries has placed greater emphasis on strategies to improve surgical safety in resource-limited settings. The implementation of surgical safety checklists in low-income countries has specificbarriers related to resources and culture. Adapting and amending existing surgical safety checklists, aswell as considering factors unique to developing countries, may allow the potential of this simpleintervention to be fully harnessed in a wider setting.

This review will address the benefits and challenges of implementation of surgical safety checklists indeveloping countries. Moreover, inspiration for the original checklist is revisited to identify areas thatwill be of particular benefit in a resource-poor setting. Potential future strategies to encourage theimplementation of checklists in these countries are also discussed.

� 2013 Surgical Associates Ltd. Published by Elsevier Ltd. All rights reserved.

1. Introduction

The surgical mortality in developing countries is 10 times higherthan developed nations1 and deaths attributed to anesthesia are1000-fold higher,2,3 clearly demonstrating the need to improvesafety in this setting. By simply implementing checklists and pro-tocols from developed countries to developing countries we maynot be harnessing their complete benefits. This reviewwill considerthe role of surgery in addressing the overall burden of disease in thedeveloping world and discuss the impact of the World Health Or-ganization Surgical Safety Checklist (WHO SSC) in this setting.Suggestions for appropriately adapting and expanding the WHOSSC for developing countries to improve the safety of surgeryglobally are also discussed.4

2. Importance of surgery in developing countries

The recent WHO report ‘Safe Surgery Saves Lives’ has helpedprioritize surgical care throughout the world.5 Surgery has previ-ously been perceived to be a cost-ineffective intervention relative

ail.com (S. Vivekanantham),), kumaran.shanmugarajah@aruthappu@post.harvard.eduoub).

ciates Ltd. Published by Elsevier Lt

to GDP in low-income countries.6 However, Gosselin et al. havemeasured the cost per Disability-Adjusted-Life-Year (DALY) in Si-erra Leone, which highlighted that the price per DALY averted was$32.78 through surgery, which compares favorably with non-surgical interventions.7 Another study in Cambodia evaluated thecost of trauma surgery and this was also deemed to be cost-effective relative to other medical interventions.8

Aside from cost being a barrier to the expansion of surgery indeveloping countries, it was also thought that surgery onlybenefited a small percentage of the population. This implied thatresources would be more effectively utilized on alternative man-agement strategies. Jamison et al. have countered this position;they have estimated that 11% of the global burden of disease can betreated by surgery, particularly by operating on those sufferingtrauma or cancer.9

These findings underpin the acknowledgment of the increasedbenefit surgery can provide in developing countries. It is vital thatas increased surgical interventions are employed in these settings,safety standards are initiated and improved in parallel.

3. Importance of the WHO SSC in the developing world

Vast differences between developed and developing countries,for example in healthcare budgets, reflect differences in measuresneeded to ensure surgical safety.9 In light of this, we believe theWHO SSC is evenmore critical in developing countries compared to

d. All rights reserved.

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developed countries. For example, surgeons in rural areas may haveto perform a higher number of operations and operate in situationswhere theymay not be specialists.10 This may lead to simple checksbeing omitted because of the pressure of the workload, as well asunfamiliarity with the procedure performed. Checklists would beparticularly useful in such settings.

TheWHO SSC was developed with the aim of routinely checkinginformation at three critical stages of surgery (Fig. 1). Use of thisinitiative has been associated with reduced operative error andimproved outcomes.4 In particular patient mortality fell from 1.5%to 0.8% following the implementation of this checklist. Importantly,this data was acquired from four high-income and four low-incomeor middle-income countries, as classified by the World Bank,11

thereby demonstrating its applicability throughout the world.4

Numerous other studies have looked into the implementation ofthe WHO SSC globally.12e14 In 2012, Borchard et al. performed asystematic review of the effectiveness of safety checklists in surgeryand encouragingly found that the relative risk of mortality fell to0.57 (95% CI: 0.42e0.76) when checklists were used.14 Furthermore,

Fig. 1. Elements of the World Health Organization Surgi

the relative risk of complications also fell after the implementationof the checklists (0.63 [95% CI: 0.58e0.67]).14

Whilst the WHO SSC was trialed worldwide, evidence suggestsit is particularly effective in a resource-poor setting. Following theimplementation of the WHO SSC, the largest decrease in compli-cations (74.3%) was in low-income or middle-income countries.4

Furthermore, in the same study, two of the four hospital sites inthe low-income and middle-income countries group had adecrease in surgical site infections and total complication rates,compared to only one of the four hospital sites in high-incomecountries.4 These findings highlight that the WHO SSC has thepotential for significant impact specifically in the context ofdeveloping countries.

A possible explanation for these observations could be that anumber of safety measures outlined in the WHO SSC were alreadyused in developed countries prior to the formal introduction of thechecklist. For example, observations from high-income countriesfrom the initial WHO SSC study showed pulse oximetry was usedfor intra-operativemonitoring in 99.0% of cases before the checklist

cal Safety Checklist. Reproduced with permission.4

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was introduced, compared to 86.0% in sites of low-income ormiddle-income countries.4 In addition, prior to the implementationof the WHO SSC, intra-operative observers noted 63.9% of cases insites of high-income countries performed an oral confirmation ofthe patient’s identity and surgical site prior to operation. However,this was only observed in 34.3% of cases in developing countries.4

These studies have identified areas in which the WHO SSC mayhave a particular impact in developing countries.

While studies on the WHO SSC have demonstrated encouragingoutcomes, its usage remains poor, with checklist compliance hav-ing been reported as low as 12%.14,15 Cultural differences may play arole in the reduced uptake of surgical safety checklists in devel-oping countries. In Thai culture, for example, it is against societalnorm to make marks on other people16 so this may prevent themmarking the operative site. Moreover, people in Thailand onlyintroduce themselves when meeting initially, and are typically shyabout expressing their position thereafter. This may explain whyteam members were more reluctant to introduce themselves byname and role during the ‘time-out’ period.17 Furthermore, eco-nomic limitations may limit the full implementation of the check-list because of the requirement of certain equipment which maynot be affordable in the developing world.18 In Thailand, surgicalsite marking and hair removal were typically not completed priorto checklist implementation.17 A contributing factor could beshortage of materials; however, these items were then acquiredfollowing the implementation of a checklist, which perhaps servedto highlight their absence.

We have established that whilst the WHO SSC has some efficacyin the developing world, there still remains scope to improve itsbenefits there. We now shift focus to concentrate on ways that thiscould potentially be done.

Fig. 2. The different stages of the Formula 1 pit stop, where numbers denote the orderof the different actions. Reproduced with permission.20

4. Developing checklists in resource-limited settings usingpast inspiration

Checklists from other industries contributed towards thedevelopment of the WHO SSC.19 In order to adapt the WHO SSC tofurther benefit surgical safety in developing countries, it may beuseful to revisit the founding principles that initially inspired thecreation of the checklist, and see if further lessons may be gleaned.

The high-pressure environment of surgery is found only in ahandful of other careers. Notably, Formula 1 (F1) racing and avia-tion both require high levels of teamwork, focus and performance,similar to that seen in an operating theater. This especially holdstrue in resource-limited theaters, often with a higher caseload. InF1, the pit stop requires the coordinated efforts of many teammembers to perform the necessary steps as efficiently as possible(Fig. 2). In many ways this parallels the post-operative handoverprocess in surgery. In developing countries there is less staff to lookafter patients and therefore correct and complete informationtransfer is critical. Considering this, variations or further criteriacould be introduced to the WHO SSC in developing countries tomaximize its benefit at the post-operative handover stage.

Catchpole et al. consulted the Ferrari F1 race director to identifysimilarities between surgical handover and racing safety.20 Thisincluded, for example, the necessity of having a designated leader(in F1 this is the ‘lollipop’ man and it was decided the anesthetistshould assume this role).20 In developing countries, the role of theanesthetist is often assumed by nursing teams. This unclear defi-nition as to who is responsible for completing the checklist maycontribute to lower usage in developing countries, due to confusionas to who should be responsible for delivering the checklist inresource-limited settings. Compliance could be improved throughcreating tailored regional definitions as to the specific person who

is responsible for conducting the WHO SSC within the operatingtheaters in developing counties.

Meticulous training and practice is required for the ideal F1 pitstop; however, there is no structured training for the post-operativehandover, especially in developing countries. Catchpole et al. ac-counts for this, in part, by highlighting the low staff turnover in F1compared to constantly rotating doctors and nurses in the health-care world. Ensuring that staff work in the same roles as far aspossible, with minimal rotation between different positions, mighthelp further reduce complication rates in resource-limited settings.

Karl mentions several other factors that vary between surgeryand the aviation industry, beyond the use of checklists.21 Forexample, in surgery there is an emphasis on documenting what isdone rather than actually focusing on doing it safely. Also in sur-gery, people are expected to know how to deal with emergencies bymemory, whilst in aviation there is a quick reference handbook forall major emergencies that can be accessed for assistance. Utilizinga similar resource in developing countries to cover a range ofemergency procedures might be a separate initiative that canimprove surgical safety globally. Finally, and importantly, below10,000 feet all airlines have ‘sterile cockpit rules’ where there canbe no discussion apart from that which is relevant to the safety ofthe flight.21 This is in contrast to surgery where there often isirrelevant discussion that is not policed, even during critical parts ofa procedure. Incorporating ‘sterile operating rules’ at key aspects ofsurgical procedures might help improve surgical safety in devel-oping and developed countries alike.

Although it is helpful to draw comparisons from other in-dustries, ultimately surgical practice is unique. Therefore, whilst

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other industries’ standards of practice can be examined, weappreciate that not all lessons can be directly translated into sur-gery. We anticipate that these lessons will form the foundationupon which improvements to surgical practice can made, takinginto account the complexity and uniqueness of surgical patients.Surgical safety checklists have been shown to reduce errors;however, they have not completely eliminated them. This high-lights the ongoing importance of good clinical judgment and theappreciation of significant inter-patient variation by gaining expe-rience as a surgeon.

5. New directions for using checklists in resource-limitedsettings

While some studies have demonstrated a positive benefit of theWHO SSC there are ways in which checklists could be furtherdeveloped. Specific checklists have been created to suit differentsurgical specialties, for example neurosurgery22 and ophthal-mology.23 At this time, it is unclear whether changes to content,structure, delivery and specialty-specificity of checklists could leadto further benefits to patient safety and quality of treatment, withmore research in this area sure to provide the answer. With case-load variations between developed and developing countries interms of volume and types of procedures, use of checklists acrossdifferent specialties created in developed countries might need tobe further modified to ensure maximal benefit for use in resource-limited settings.

Although surgical research has been quick to embrace the po-tential of checklists, the adoption of checklists beyond the oper-ating room has been limited.24 Checklists have been harnessedrecently in cardiac catheterization25 and crisis situations.26 Withfurther clinical situations trialing checklists in the developed world,it will becomemore readily apparent where benefit may be derivedthrough their implementation and give direction for further uses ofchecklists in developing settings.

In order to improve compliance in developing countries it maybe useful to adjust the WHO SSC, taking cultural variations intoaccount. Surgical practitioners of various ethnicities in differentcountries could be consulted to identify any specific areas of thechecklist that might present a barrier to its uptake in regions withdifferent social norms. Amendments could then be made toaccommodate cultural variations.

The efficacy of the WHO SSC has inspired the formation ofvarious sister organizations that promote the use of medicalchecklists worldwide. Project Check is an umbrella organizationthat aims to act as a central source for all clinical checklists. Theorganization aims to make clinical checklists suitable for manydifferent situations globally, enhancing safety around the world.15

Furthermore, the charity Lifebox was created to subsidize the costof purchasing pulse oximeters by hospitals in developing countriesas this may be a barrier to full implementation of the checklist inthese settings.27 More recently, a study has demonstrated thatsuccessful implementation of the WHO SSC with provision of pulseoximeters in a resource-limited setting in Moldova resulted in areduction in overall post-operative complications from 21.5% to8.8%.28 Further initiatives to support the global implementation ofchecklists will help reduce surgical complications in developingsettings.

‘Checklist fatigue’ is when the overuse of checklists results inreduced overall compliance. The WHO SSC is designed to minimizethis by only including checks for common and preventable sourcesof error.19 With the occurrence of ‘checklist fatigue’ recognized inthe developed world,29,30 measures to prevent this should beenforced in resource-limited settings. We believe this limitation isless likely to occur if the previously outlined benefits of using

checklists are stressed to those responsible for checklist compliancein developing countries. We also propose that following a reas-sessment of the components of the checklist, the checklist shouldbe tailored specifically to various developing world settings, takinginto account cultural differences and local practices; only onechecklist should be implemented within a country or region.

6. Conclusions

It is estimated that at least half a million deaths per year wouldbe prevented worldwide if the WHO SSC was correctly imple-mented.31 Any human system is prone to error; however, checklistsare proving to be an effectivemechanism throughwhich this can bereduced within surgery and beyond. We believe the benefits fromthese measures will be of particular value in developing countries,where resources and surgical practice lag behind that of developedcountries.

Inspiration for developing safety checklists originated fromexamining protocols from other industries, where maintainingsafety is considered as important as achieving an outcome. Theseindustries provide ideas for further development of surgical safetychecklists, and there is an impetus to implement more ideas fromthese other fields to improve the efficacy of checklists in developingcountries. Whilst we acknowledge that checklists cannot replacegood clinical acumen, we feel that there is still scope for improvingsafety by increasing and adapting the usage of this tool in thedeveloping world.

Interventions to improve surgical safety through checklists e

whether pre-operatively, during surgery, post-operatively, or in acrisis setting e may also act as inspiration for other areas of med-icine. The direction and future application of these initiatives holdsmany possibilities and remains an exciting opportunity to furtherdrive down adverse outcomes within surgery, particularly indeveloping settings.

Conflicts of interestSayinthen Vivekanantham is founding Director of Global Med-

ical Education Trust (GMET), a recently established charity thataims to improve the quality of medical education and learningwithin healthcare in developing countries. Mahiben Maruthappu &Joseph Shalhoub are co-founding Directors and Kumaran Shan-mugarajah is the Secretary of theWorld Surgical Association (WSA),a recently established non-profit improving surgical care deliveryin resource-limited settings. They have no other conflicts of interestto declare.

FundingNone.

Ethical approvalNone.

Author contributionSayinthen Vivekanantham e Extrapolation of initial concept,

drafting of the article, ideas for initiatives.Rahul Prashanth Ravindran e Drafting of the article, ideas for

initiatives.Kumaran Shanmugarajah e Review and editing of the article.Mahiben Maruthappu e Review and editing of the article.Joseph Shalhoube Conception of idea, review and editing of the

article.

Acknowledgments

None.

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