Published 11/1/2013
Gregory H. Sirounian, MD

Using Checklists to Ensure Patient Safety

Consistency is key

The regular use of surgical checklists—standardized, validated, evidence- or consensus-based processes—promotes consistency in surgery and helps provide safe, efficient, high-quality surgical patient care. The AAOS Patient Safety Committee identifies consistency through the use of checklists as one of the six “Critical Cs of Surgical Safety.” (In addition to consistency, the six critical Cs include consent, confirmation, communication, concentration, and collection.)

Like professionals in many other industries, surgeons face increasingly complex challenges in an ever-changing healthcare environment. As surgeons, we have traditionally relied on our technical knowledge and skill to provide the best outcomes for our surgical patients. We now know that nontechnical knowledge and skills, as well as human factors, are equally important.

As surgeons, we need to build and use highly reliable systems to support our surgical teams. In recent years, consistent use of reliable surgical processes, such as surgical checklists, has become as critical to safety and outcomes as the surgical instruments and implants we use daily.

Although checklists are relatively new to surgery, they have been successfully used in other industries for many years. Many surgeons are familiar with the use of checklists in aviation as a highly reliable tool to prevent deadly errors and improve safety. In addition, checklists are used commonly in other industries, including building construction, food service, and entertainment. As consumers we aren’t necessarily aware that checklists are used in these industries, but we have come to expect the safe, high-quality products and services resulting from their use. Orthopaedic surgery should be no different. Healthcare consumers expect consistent, safe, and high-quality services from their musculoskeletal healthcare providers.

The basics of surgical checklists
In his 2009 book, The Checklist Manifesto—How to Get Things Right, Atul Gawande, MD, introduced the rationale for surgical checklists. Working with the World Health Organization (WHO), he helped develop a 19-point preoperative checklist designed for use by all members of the surgical team, including the surgeon, anesthesiologist, circulating nurse, and other operating room (OR) team members. The WHO checklist is divided into the following three sections:

  1. The brief. The brief confirms important safety information prior to anesthesia administration: proper patient identification, surgical site marking, surgical consent, a functioning pulse oximeter connected to the patient, patient’s medication allergies, potential airway problems, and availability of blood products, if needed.
  2. The time out. Performed immediately prior to the surgical incision, the time out enables the OR team to confirm correct patient, procedure, surgical site, appropriate antibiotic administration, radiographic images, anticipated length of surgery, blood loss, and to address any critical surgical concerns.
  3. The debrief. Completed at the end of the surgery, but prior to leaving the OR, debrief checks confirm and record the accurate name of the procedure; labeling of pathology tissue specimens; correct needle, sponge, and instrument counts; and identify surgical equipment problems.

The WHO checklist supports a culture of safety and its use has demonstrated reductions in surgical complications across a broad spectrum of hospitals worldwide. Although the specific steps in the WHO checklist may not necessarily be appropriate for every orthopaedic procedure, the formalized use of a similar perioperative routine should be used universally in all surgical settings.

Tools and teamwork
Surgical checklists are not designed to take the surgical team step-by-step through the surgery or serve as a substitute for sound clinical judgment and surgical skill. Checklists are designed as evidence-based tools to help avoid preventable harm to patients, promote a culture of safety, and increase teamwork in the OR.

Checklists should not add to the complexity of surgery. Rather, when performed consistently, checklists actually help standardize and simplify most basic OR functions. Surgical teams can develop concise, reproducible safety systems that, in most instances, add only one or two minutes per case.

The use of checklists efficiently and effectively addresses important safety concerns and enables surgical team members to focus on the procedure itself, as well as the surgical patient. Rather than impeding progress, well-executed checklists should help surgical teams and surgeons proceed confidently with surgery, knowing that the team is doing everything in its power to prevent devastating complications and deliver the best care possible.

Patient safety is a team sport. Through the effective use of surgical checklists, surgeons can develop OR teams that function exceedingly well together. It has been shown that even the simple introduction of team members to each other at the start of a case leads to more effective team communication throughout the day. Moreover, by enlisting all team members—including patients and their families—into the checklist process, surgeons encourage greater participation in minimizing, with a goal of eliminating, avoidable surgical harm.

Although it appears that this might diminish surgeon authority and autonomy, checklists actually help team leaders function more effectively, resulting in more effective surgeon leadership.

As health care evolves, our performance as surgeons will face broader and deeper scrutiny from government entities, payers, employers, and patients, among others. Significant attention will be directed toward our ability to provide—and document—safe, consistent, surgical care. Checklists are an important tool that can help us keep pace with these expectations while maintaining focus on our patients’ welfare.

The AAOS is dedicated to promoting a culture of safety in all orthopaedic surgical settings. Following the 2012 Orthopaedic Safety Summit, several orthopaedic-oriented checklists are being developed for pediatrics, adult reconstruction, ambulatory surgery, opioid safety, identification of correct-level spine surgery, and improvements in hip fracture care.

Gregory H. Sirounian, MD, is a member of the AAOS Patient Safety Committee.


  1. Kuo CC, Robb WJ 3d: Critical roles of orthopaedic surgeon leadership in healthcare systems to improve orthopaedic patient safety. Clin Orthop Relat Res. 2013 Jun;471(6):1792-800
  2. Gawande A: The Checklist Manifesto: How To Get Things Right. New York, Metropolitan Books, 2009.
  3. World Alliance for Patient Safety: WHO surgical safety checklist – First Edition. 2008.

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