WHO Surgical Safety Checklist: A safety procedure that should be applied unwaveringly in every operating theatre.

Introduction

The faithful implementation of the WHO Surgical Safety Checklist—a global checklist designed to make surgical procedures safer—is a non-negotiable process before any operation begins.

What is the WHO Surgical Safety Checklist?

The WHO Surgical Safety Checklist (as designated by the World Health Organization, WHO) is a 19-point international checklist created by the World Health Organization to make surgical procedures safer. It is used before, during, and at the end of the operation to ensure the team does not overlook any essential patient safety steps.

Studies have shown that using the checklist achieves maximum safety in the operating theatre. It is not merely a "form to fill out", but a tool for team communication and safety within the theatre.

Why was such a checklist needed?

Millions of surgical procedures are performed every year, and a significant proportion of complications stem from preventable human errors. Wrong patient, wrong side, untimely antibiotic administration, forgotten instruments or swabs, equipment issues—these are rare, but when they occur, the consequences are severe.

The World Health Organization developed the checklist as part of the "Safe Surgery Saves Lives" initiative (meaning safe surgery saves lives), aiming to reduce preventable surgery-related harm. The goal is to establish a simple, shared safety routine applied uniformly in small and large hospitals, public and private sectors, and across all specialties.

The three stages of the checklist

The checklist is divided into three key stages, each tied to specific moments during the operation. At each stage, the team pauses for a few minutes, conducts a brief "safety check", and verbally confirms the critical points.

1. Sign In – Before anaesthesia

This occurs before the patient receives anaesthesia, aiming to verify basic identity and risk elements. It is usually coordinated by the theatre nurse in collaboration with the anaesthesia team.

Checks include, among others:

• Patient's full name, procedure, and site/side (matching the consent form and wristband).

• Whether the surgical site is correctly marked (e.g., right/left).

• Any severe allergies, risk of difficult airway or aspiration, and estimated risk of major blood loss.

• Availability of blood, venous access, resuscitation equipment, and any special implants or devices needed (e.g., neuromonitoring, C-arm, etc.).

  
  

2. Time Out – Before the incision

This takes place once the patient is anaesthetised, just before the incision. The entire team stops, makes eye contact, and verbally confirms the critical points.

It includes:

• Final confirmation of the correct patient, correct procedure, and correct side.

• Confirmation that antibiotics were given at the right time (usually within 60 minutes before incision).

• The surgeon briefly outlines the procedure plan, expected duration, and critical stages.

• The anaesthesia team reports any special risks (e.g., haemodynamic instability, comorbidities, intubation difficulties).

• The nursing team confirms that all necessary instruments, implants, and materials are available and functioning.

  
  

3. Sign Out – Before the patient leaves theatre

This occurs towards the end, before the patient is transferred to recovery or the ward. The aim is to safely conclude the procedure and ensure proper continuity of care.

It includes:

• Counting swabs, instruments, and needles to confirm nothing has been left inside the patient.

• Checking that all specimens (e.g., biopsies, tumours) are correctly labelled and accompanied by proper request forms.

• Reviewing any equipment issues for correction in future cases.

• Brief agreement on the postoperative plan: analgesia, antibiotics, special instructions, need for ICU, imaging checks, etc.

  
  

What does the patient gain?

Using the checklist is linked to clear improvements in outcomes and patient safety. A large WHO multicentre study showed reduced major complications after checklist implementation across different countries and settings.

Key benefits include:

• Fewer preventable complications such as surgical site infections, haemorrhage, thromboembolic events, and respiratory issues.

• Reduction in errors like wrong side, wrong procedure, or wrong patient.

• Better team coordination, leading to faster problem recognition and timely intervention.

• Strengthening of the hospital's safety culture, benefiting all patients in the long term.

  
  

The team's role and challenges

The checklist works best when the entire team embraces it as an integral part of daily practice, not a bureaucratic obligation. Once it becomes routine, it takes just minutes but provides significant patient safety and better team organisation.

Despite the benefits, resistance persists in some hospitals, often due to lack of training, time pressure, or the notion that "it's unnecessary, we know it all". Experience shows even highly experienced teams benefit from a structured, shared verification process.

It is a core principle of Dr Mazarakis and his team to apply the WHO checklist unwaveringly, so every patient knows—regardless of how simple or complex the surgery—that there are no compromises on surgical safety protocols. Our absolute priority is patient trust and peace of mind.

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