CONTINUING EDUCATION
Back to Basics:
Implementing the Surgical
Checklist
LISA SPRUCE, DNP, RN, ACNS, ACNP, ANP, CNOR
Continuing Education Contact Hours
indicates 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
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Session: #0001
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The CE contact hours for this article expire November 30,
2017. Pricing is subject to change.
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 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.
Accreditation
AORN is accredited as a provider of continuing nursing
education by the American Nurses Credentialing Center’s
Commission on Accreditation.
http://dx.doi.org/10.1016/j.aorn.2014.06.020

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1.7
www.aorn.org/CE
Approvals
This 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 Disclosures
Lisa 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 Support
No sponsorship or commercial support was received for this
article.
Disclaimer
AORN 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.
November 2014 Vol 100 No 5
AORN Journal j 465
Back to Basics:
Implementing the Surgical
Checklist
LISA 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.

I
n 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
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 BACK TO BASICS: SURGICAL CHECKLIST

Figure 1. The WHO Surgical Safety Checklist. Reprinted with permission from the World Health Organization, Geneva, Switzerland.
www.aornjournal.org

AORN Journal j 467

November 2014 Vol 100 No 5
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
468 j AORN Journal
SPRUCE
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
 BACK TO BASICS: SURGICAL CHECKLIST

Figure 2. The AORN Comprehensive Surgical Checklist. Reprinted with permission from AORN, Inc. Copyright ª 2014. All rights reserved.
www.aornjournal.org

AORN Journal j 469

November 2014 Vol 100 No 5
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
470 j AORN Journal
SPRUCE
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
BACK TO BASICS: SURGICAL CHECKLIST
Figure 3. This What’s Wrong with This Picture? illustration suggests some of the reasons that checklists fail to
prevent surgical errors.
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.
www.aornjournal.org
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.
AORN Journal j 471
November 2014 Vol 100 No 5 SPRUCE

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.
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-

n Ask all team members to stop and listen to the mentation,

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
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

Resources for Surgical Checklist Implementation patient safety efforts,

n recognize their role in
Web sites patient safety, and
n AORN Comprehensive Surgical Checklist. AORN, Inc. http:// n value multidisciplinary
www.aorn.org/Clinical_Practice/ToolKits/Correct_Site_Surgery_ involvement.
Tool_Kit/Comprehensive_checklist.aspx.
n Patient Safety Tool: SURPASS Checklist. Becker’s Infection
and Quality Control. http://www.surpass-checklist.nl/dlChecklist WRAP-UP
.jsf;jsessionid¼0FEB76A00DA444AA208CACA34C07F0E1? The evidence supports sur-
pageId¼Download&lang¼en. gical safety checklist use in
n WHO Surgical Safety Checklist Implementation Guide. World the perioperative setting to
Health Organization. http://www.who.int/patientsafety/safesurgery/ help decrease the risk of a
checklist_implementation/en/. patient safety event and to
n WHO Surgical Safety Checklist. World Health Organization anticipate potential patient
(WHO). http://www.who.int/patientsafety/safesurgery/ issues postoperatively.6,8-13
checklist/en/. The key is proper use and
actually completing the
Videos
checklist steps. This “Back
n Harvard team using the WHO Surgical Safety Checklist. Lifebox
to Basics” article provides
Foundation. https://www.youtube.com/watch?v¼wgqIkhkXYMQ.
key strategies that can be
n How not to perform the WHO Safe Surgery Checklist.
used to implement a check-
WHOSurgeryChecklist. https://www.youtube.com/watch?
list and some strategies for
v¼DOGJMOMHDJk.
success. Using these strate-
n WHO surgery saves lives checklist. WHOSurgeryChecklist.
gies will give perioperative
https://www.youtube.com/watch?v¼CIFhLUiT8H0.
nurses, leaders, surgeons,
Web access verified June 11, 2014. and other team members
the tools to successfully

472 j AORN Journal

BACK TO BASICS: SURGICAL CHECKLIST
implement a checklist that can help improve pa-
tient safety.
References
1. 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
Check back in January 2015 for the next “Back to Basics” topic: Evidence-Based Practice.
www.aornjournal.org
.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.
AORN Journal j 473
EXAMINATION
1.7
CONTINUING EDUCATION

Back to Basics: Implementing the www.aorn.org/CE

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 2. conducting informal surgeon-to-surgeon

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.
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

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CE EXAMINATION www.aornjournal.org

4. Strategies for successfully implementing a surgical 5. asking questions if any team member looks unsure.
checklist include 6. reading from the checklist every time instead
1. providing a laminated checklist, a checklist of relying on memory.
board, or an electronic checklist that all team a. 1, 3, and 5 b. 2, 4, and 6
members can see easily. c. 2, 3, 5, and 6 d. 1, 2, 3, 4, 5, and 6
2. having all team members, including stu-
dents, introduce themselves before every 5. The keys to successfully using a surgical safety
procedure. checklist are
3. ensuring that surgeons have an active role in 1. using the checklist properly.
the checklist process by asking them to be 2. using colors to highlight the most important
leaders of the process. areas on the checklist.
4. asking all team members to stop and listen 3. actually completing the checklist steps.
to the surgeon or RN circulator who is con- 4. forcing surgeons to use checklists.
ducting the checklist and ensuring all agree a. 1 and 2 b. 1 and 3
on the information before proceeding. c. 2 and 4 d. 3 and 4

AORN Journal j 475

LEARNER EVALUATION
CONTINUING EDUCATION PROGRAM
Back to Basics: Implementing the
Surgical Checklist
T
his 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
476 j AORN Journal
November 2014 Vol 100 No 5
1.7
www.aorn.org/CE
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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