Implementation of Surgical Safety Checklists in Orthopaedic Surgery: A Narrative Review of Compliance, Barriers, and Future Improvements

Abstract

The introduction of the World Health Organization's (WHO) Surgical Safety Checklist (SSC) marked a turning point in global surgical safety, standardising perioperative processes and promoting teamwork across disciplines. While the SSC has demonstrated significant reductions in surgical morbidity and mortality, its implementation in orthopaedic surgery remains uniquely challenging due to procedural complexity, implant verification demands, and frequent laterality checks. Despite high reported compliance, persistent errors such as wrong-site surgery, equipment malfunction, and implant mismatch underscore a disconnect between checklist completion and true surgical readiness. This narrative review examines the evolution, current use, and effectiveness of the SSC within orthopaedic surgery, highlighting barriers such as hierarchical theatre culture, workflow pressures, and logistical challenges that often reduce engagement to a "tick-box" exercise. Facilitators, including leadership involvement, multidisciplinary communication, simulation-based training, and continuous audit feedback mechanisms, have been identified as key enablers of sustained improvement. Emerging innovations such as digital checklist integration, real-time data auditing, and artificial intelligence-assisted verification present new opportunities to enhance reliability, accountability, and adaptability in orthopaedic theatres. However, achieving meaningful and lasting impact requires a paradigm shift from procedural adherence to behavioural fidelity and cultural transformation. The review concludes by outlining a future research agenda focused on orthopaedic-specific checklist tailoring, contextual implementation science, and development of standardised outcome metrics. Ultimately, the goal is to evolve the SSC from a procedural formality into an adaptive safety framework that reflects the complexity and precision of modern orthopaedic surgery.