T h e new england journal o f medicine n engl j med 360 5 nejm.org january 29, 2009 491 special article A Surgical Safety Checklist to Reduce Morbidity and Mortality in a Global Population Alex B. Haynes, M.D., M.P.H., Thomas G. Weiser, M.D., M.P.H., William R. Berry, M.D., M.P.H., Stuart R. Lipsitz, Sc.D., Abdel-Hadi S. Breizat, M.D., Ph.D., E. Patchen Dellinger, M.D., Teodoro Herbosa, M.D., Sudhir Joseph, M.S., Pascience L. Kibatala, M.D., Marie Carmela M. Lapitan, M.D., Alan F. Merry, M.B., Ch.B., F.A.N.Z.C.A., F.R.C.A., Krishna Moorthy, M.D., F.R.C.S., Richard K. Reznick, M.D., M.Ed., Bryce Taylor, M.D., and Atul A. Gawande, M.D., M.P.H., for the Safe Surgery Saves Lives Study Group* From the Harvard School of Public Health (A.B.H., T.G.W., W.R.B., A.A.G.), Massa- chusetts General Hospital (A.B.H.), and Brigham and Women���s Hospital (S.R.L., A.A.G.) ��� all in Boston University of California���Davis, Sacramento (T.G.W.) Prince Hamzah Hospital, Ministry of Health, Amman, Jordan (A.-H.S.B.) Uni- versity of Washington, Seattle (E.P.D.) College of Medicine, University of the Philippines, Manila (T.H.) St. Stephen���s Hospital, New Delhi, India (S.J.) St. Fran- cis Designated District Hospital, Ifakara, Tanzania (P.L.K.) National Institute of Health���University of the Philippines, Manila (M.C.M.L.) University of Auck- land and Auckland City Hospital, Auck- land, New Zealand (A.F.M.) Imperial College Healthcare National Health Ser- vice Trust, London (K.M.) and University Health Network, University of Toronto, Toronto (R.K.R., B.T.). Address reprint re- quests to Dr. Gawande at the Depart- ment of Surgery, Brigham and Women���s Hospital, 75 Francis St., Boston, MA 02115, or at safesurgery@hsph.harvard.edu. *Members of the Safe Surgery Saves Lives Study Group are listed in the Appendix. This article (10.1056/NEJMsa0810119) was published at NEJM.org on January 14, 2009. N Engl J Med 2009 360:491-9. Copyright �� 2009 Massachusetts Medical Society. Abstract Background Surgery has become an integral part of global health care, with an estimated 234 million operations performed yearly. Surgical complications are common and often preventable. We hypothesized that a program to implement a 19-item surgical safety checklist designed to improve team communication and consistency of care would reduce complications and deaths associated with surgery. Methods Between October 2007 and September 2008, eight hospitals in eight cities (Toronto, Canada New Delhi, India Amman, Jordan Auckland, New Zealand Manila, Phil- ippines Ifakara, Tanzania London, England and Seattle, WA) representing a vari- ety of economic circumstances and diverse populations of patients participated in the World Health Organization���s Safe Surgery Saves Lives program. We prospec- tively collected data on clinical processes and outcomes from 3733 consecutively enrolled patients 16 years of age or older who were undergoing noncardiac surgery. We subsequently collected data on 3955 consecutively enrolled patients after the introduction of the Surgical Safety Checklist. The primary end point was the rate of complications, including death, during hospitalization within the first 30 days after the operation. Results The rate of death was 1.5% before the checklist was introduced and declined to 0.8% afterward (P = 0.003). Inpatient complications occurred in 11.0% of patients at baseline and in 7.0% after introduction of the checklist (P0.001). Conclusions Implementation of the checklist was associated with concomitant reductions in the rates of death and complications among patients at least 16 years of age who were undergoing noncardiac surgery in a diverse group of hospitals. The New England Journal of Medicine Downloaded from nejm.org on May 15, 2012. For personal use only. No other uses without permission. Copyright �� 2009 Massachusetts Medical Society. All rights reserved.

T h e new england journal o f medicine n engl j med 360 5 nejm.org january 29, 2009 492 Sestimated urgical care is an integral part of health care throughout the world, with an 234 million operations performed annually.1 This yearly volume now exceeds that of childbirth.2 Surgery is performed in every com- munity: wealthy and poor, rural and urban, and in all regions. The World Bank reported that in 2002, an estimated 164 million disability-adjusted life- years, representing 11% of the entire disease bur- den, were attributable to surgically treatable con- ditions.3 Although surgical care can prevent loss of life or limb, it is also associated with a consid- erable risk of complications and death. The risk of complications is poorly characterized in many parts of the world, but studies in industrialized countries have shown a perioperative rate of death from inpatient surgery of 0.4 to 0.8% and a rate of major complications of 3 to 17%.4,5 These rates are likely to be much higher in developing countries.6-9 Thus, surgical care and its attendant complications represent a substantial burden of disease worthy of attention from the public health community worldwide. Data suggest that at least half of all surgical complications are avoidable.4,5 Previous efforts to implement practices designed to reduce surgical- site infections or anesthesia-related mishaps have been shown to reduce complications significant- ly.10-12 A growing body of evidence also links teamwork in surgery to improved outcomes, with high-functioning teams achieving significantly reduced rates of adverse events.13,14 In 2008, the World Health Organization (WHO) published guidelines identifying multiple recommended practices to ensure the safety of surgical patients worldwide.15 On the basis of Table 1. Elements of the Surgical Safety Checklist.* Sign in Before induction of anesthesia, members of the team (at least the nurse and an anesthesia professional) orally confirm that: The patient has verified his or her identity, the surgical site and procedure, and consent The surgical site is marked or site marking is not applicable The pulse oximeter is on the patient and functioning All members of the team are aware of whether the patient has a known allergy The patient���s airway and risk of aspiration have been evaluated and appropriate equipment and assistance are available If there is a risk of blood loss of at least 500 ml (or 7 ml/kg of body weight, in children), appropriate access and fluids are available Time out Before skin incision, the entire team (nurses, surgeons, anesthesia professionals, and any others participating in the care of the patient) orally: Confirms that all team members have been introduced by name and role Confirms the patient���s identity, surgical site, and procedure Reviews the anticipated critical events Surgeon reviews critical and unexpected steps, operative duration, and anticipated blood loss Anesthesia staff review concerns specific to the patient Nursing staff review confirmation of sterility, equipment availability, and other concerns Confirms that prophylactic antibiotics have been administered ���60 min before incision is made or that antibiotics are not indicated Confirms that all essential imaging results for the correct patient are displayed in the operating room Sign out Before the patient leaves the operating room: Nurse reviews items aloud with the team Name of the procedure as recorded That the needle, sponge, and instrument counts are complete (or not applicable) That the specimen (if any) is correctly labeled, including with the patient���s name Whether there are any issues with equipment to be addressed The surgeon, nurse, and anesthesia professional review aloud the key concerns for the recovery and care of the patient * The checklist is based on the first edition of the WHO Guidelines for Safe Surgery.15 For the complete checklist, see the Supplementary Appendix. The New England Journal of Medicine Downloaded from nejm.org on May 15, 2012. For personal use only. No other uses without permission. Copyright �� 2009 Massachusetts Medical Society. All rights reserved.