Safer Surgical Checklist – Literature Review

November 7, 2021


Mr Nigel Roberts, MSc, BA (Hons), PGR student,

Theatre Lead, University Hospitals of Derby and Burton


Professor Stephen Wordsworth,

University of Derby

Professor Denis Anthony,

University of Derby

Keywords: Never events, Surgery safety checklist, Airline industry, Barriers, Non-technical skills, Education, Local champions, Wrong site surgery, Retained foreign object post procedure, Wrong implant/prosthesis


A review of the literature on the safer surgical checklist to understand why never events are still occurring in the operating theatres across the National Health Service as well as globally.


Our aim is to understand the barriers that are affecting the effective use and implementation of the surgical safety checklist to understand what further work, research, and education is required to either limit or stop never events from occurring intra-operatively.


Six databases were searched, with a date range of 2009 – 2021.


CINAHL n = 23, Cochrane library n = 2, Embase n – 81, Researchgate n = 60, Scopus n = 53 and additional sources from websites n = 28.

From the initial search, a total of 261 papers were found across six databases. The records were screened, and duplicates removed, this left a total of 53 papers to be assessed for eligibility. This was further reduced by 11 as the literature was either not accessible or relevant to the topic. From other sources such as websites and organisations a further 28 papers were deemed to be appropriate to be included in the study.

The above has been reviewed and presented in a synthesised framework in appendix one, pages 22 – 26.


Papers published in English, peer reviewed, and academic journals restricted to 2009-2021.

# (surgical checklist) AND (patient safety) AND operating theatre OR surgery Or operating room

The search was carried out between 26th July 2021 and the 10th August 2021.

Appendix 2, page 27, details a PRISMA diagram of the search.

Exclusion criteria:

Animals, not written for a theatre environment, the abstract or title was deemed not relevant and not published in English


Examining the literature on the safer surgery checklist, a combination of seventy articles, journals and websites were reviewed. The main themes identified were ones of barriers, culture, training, non-technical skills, local champions, and surgical safety checklist per speciality.


All operating theatres encounter a complex working environment, daily time pressures, high workloads, and have the potential for catastrophic results if errors occur. The checklists that are used across the world today are based upon three principles, simplicity, widespread applicability, and measurability (WHO, 2008).


The main objective of this narrative review is to present a transparent process whereby: –

  • We systematically searched databases to identify studies on the safer surgical checklist
  • We describe the sources of the studies and any impact on patient care
  • We show the re-occurring themes from across twelve years of studies

Research question:

Why are never events still occurring intra-operatively in our operating theatres?


Surgical safety checklist background

Recognition of theatres being a hazardous environment was made by Thomas et al (2000) and De Vires et al (2008) when it was estimated that nearly half of the adverse events that occur, are preventable. The ethos of a checklist is to help identify mistakes before any harm is caused to patients. Helmreich (2000) reported that checklists are commonly used as a method of both error and safety management to reduce risk. Haynes et al (2009) demonstrated that the use of a simple checklist can reduce the risk of morbidity, mortality and surgical site infection associated with surgery. Checklists not only reinforce communication (McConnell et al, 2012) but also improve communication (Gillespie et al, 2010 & Low et al, 2012) amongst all the multidisciplinary team.

In 2009, the World Health Organisation (WHO) launched guidelines for safe surgery saves life (WHO, 2009) in six languages (Haynes et al, 2009), across 132 countries (Gillespie et al, 2018) with the aim of preventing unnecessary death and improving outcomes for surgical patients (Viswanath et al, 2017), consequently, nineteen items were compiled into the three steps, for the original WHO safer surgery checklist (SSC). However, later in December 2010 following feedback from the initial implementation, a further two steps were added, these were the team brief and debrief. (Shah, 2011)

In January 2009 (Braham et al, 2014), the National Health Service (NHS) authorised the use of the checklist, and the National Patient Safety Agency (NPSA) (2008) stated that all NHS trusts must adopt this very simple and effective intervention. From February 2010 the NPSA checklist became a mandatory requirement for all operations in NHS England (NPSA, 2010). It was mandated by the NHS Commissioning Board Special Health Authority (Braham et al, 2014).

Learning from the airline industry

However, checklists are not new, the NHS has adopted this methodology from other sectors that use checklists daily, mainly the airline industry as the operating theatres have similar comparisons of time pressure, high workloads, and a potential for catastrophic errors, as previously stated. The first checklist was introduced into aviation after an accident on the 30th October 1935 when the United States army corps was looking for its next generation of long range bombers. The plane took off, climbed up to 300 feet, staled and crashed. This was due to the pilot forgetting to release a new locking mechanism (Gawande, 2007). Later in the 1970s, aviation introduced its first cockpit resource management (CRM) programme into its training (Helmreich, 2000), initially it was only available to captains. However, a decade later, CRM was extended to all flight crew members and engineers.

Early adoption of the surgical safety checklist

When the checklist was introduced in 2009, the World Health Organisation (WHO) indicated that the checklist is not intended to be comprehensive, additions and modifications were encouraged (WHO, 2009). This was supported by Harden (2013) as it was suggested that checklists are not one size fits all, they must be customised to fit local practice. Verdassdonk et al (2009) had previously suggested that if the checklist is modified, it may influence its efficiency but, if it is too long or difficult, it may have a negative effect or no effect at all. McConnell et al (2012) found similar findings as they suggested the checklist should remain succinct and concise, otherwise checklist fatigue may occur. Thimbleby (2013) stated that checklists need to be tailored for different procedures. However, Pugel et al (2015), suggested that adopting a checklist to fit local practice may promote ownership and could improve compliance. Raman et al (2016) suggested that checklists need to be tailored to the specific task being performed. The use of stock questions decreases the likelihood of ensuring all theatre personnel are attentive. This was supported by both Raman et al (2016) and Barbanti-Brodano et al (2020) as they suggested specialised checklists reduce adverse events.

Second time out

Song et al (2013) suggested a second time out, a second checklist that is conducted three to four hours after the start of surgery to assess patient safety. The second checklist will promote communication between the surgical, anaesthetic and theatre staff whilst addressing concerns that may impact on prolonged operations. Song et al (2015) later reported that this initiative received positive feedback from all surgeons. A few years later, Schwab (2017) stated that we are now living in a new era, the fourth industrial revolution and Westman et al (2020), suggested that future studies should consider the use of checklists for robotic surgeries and artificial intelligence. Whilst conducting the literature review on the surgical safety checklist, it became apparent that there is still more research needed to understand the potential benefits of a second time out. The current papers were limited from the databases searched, and given that surgeries are complex, and multiple procedures are lasting longer than four hours, this is an area that needs to be explored further to ascertain, what, if anything, the benefits a second time out could have on patient outcomes, both immediately following surgery and thirty days post op.

Barriers to the implementation of the surgical safety checklist

What are the barriers to the SSC, and are we getting any closer to removing them altogether, as Fourcade et al (2012) and Levy et al (2012) earlier research, suggested that despite the awareness of the safer surgical checklist, most hospitals were struggling with effective implementation? Mahajan (2011) early research suggested that some barriers to implementation included anxiety; timing; duplication; relevance and misuse. Hurtado et al (2012) study concluded that knowledge of when to use the checklist was a definitive barrier to effective implementation. Levy et al (2012) American study also concluded that there was a lack of understanding and familiarity of the checklist amongst staff. Later in 2014, Treadwell et al, reported that the perceived barriers fell in to four categories; confusion; pragmatic challenge; access to resources and individual beliefs and attitudes. A year later, in 2015, Treadwell et al, still noted that there were barriers, but in fact identified five main categories; staff perception, workflow; design and content of the checklist; implementation and local context. Gillespie et al (2018) in their Australian study stated that the most significant barriers to using the SSC were workflow, knowledge, contents, and clinical leadership.

To successfully implement the safer surgical checklist Collins et al (2014) suggested that key stakeholders are identified, a change in culture and a shared vision for safety and active communication were all required. This theory was supported as both Bergs et al (2015) and Gillespie et al (2018) suggested that there is evidence identifying both contextual and organisational challenges in relation to checklist adoption.

To lead the change and to implement the SSC Vats et al (2010) suggested that the use of local champions will help in achieving complete adoption of the checklist. This theory was previously supported by Reinertsen et al (2007), Paull et al (2009) and Sewell et al (2013). Mahajan (2011) found that for successful implementation, three essential elements were required. They were developing local champions, organisational leadership, and training. Conley et al (2011) stated that a local champion can lead implementation by educating and supporting team members, as this will also help reduce the perceived barriers as previously mentioned. O’Connor et al (2013) study in Ireland found that by having a designated local champion it helped to remove any barriers and ensured the SSC was used. Oppikofer and Schwappach, (2017) suggested that hospital leadership is essential as acceptance comes from the participation of the users.

Other challenges associated with the use of the SSC whilst undertaking this literature review was one of time. An early study in France by Fourcade et al (2102) concluded the SSC was considered a waste of time as it took staff too long to complete, when their workload is already busy. There was also a perception of no actual added patient benefit. A study in Canada by Urbach et al (2014) found that the SSC added steps, that caused unnecessary delays in an already busy operating theatres schedule. Treadwell et al (2014) similarly reported that staff felt the checklist decreased efficiency in the operating room. In 2016, Tian et al study reported that the WHO checklist was still relevant and important but concluded that adequate time must be provided for checklist completion as this will lead to both ‘buy in’ from staff and ultimately improve patient safety. Barimani et al (2020) concluded that a major barrier to adoption of the SSC was the lack of a streamlined and cohesive approach in implementation.

In the current climate, where the NHS and other health care organisations from around the world, are faced with high demands on an already stretched service, we must consider the staff, and potentially how fatigued they are all feeling following Covid-19, and the pressures placed on NHS trusts by the government to tackle a growing backlog of patients that require not only surgical intervention, but also other NHS services. The current waiting lists are at a fourteen-year high, and there is an estimated 4.7m people waiting for treatment to begin (O’Dowd, 2021).

What is a never event?

The next question to ask is, so why are never events still occurring, if the SSC is in daily use? The literature would suggest that there are still six areas that require further research, education, and training. NHS England (2021) defines a never events as:

Serious incidents that are entirely preventable because guidance of safety recommendations providing strong systematic barriers are available at a national level and should have been implemented by all healthcare providers

Healthcare is complex and hence riddled with the potential for errors due to human factors (IOM, 2001). Surgery is one example of where clinicians are faced with high levels of uncertainty in their daily work, which may impact on the quality and safety of care patients receive (Tucker and Spears, 2006).

Slips and lapses are generally the result of fatigue, stress and emotional or sensory distraction (Systems approach, 2012). Over the years, much effort has been made to train surgeons and theatre staff in technical skills, but the aspects of non-technical skills, namely teamwork, leadership, situational awareness, decision making, task management and communication have long been neglected (Oppikofer and Schwappach, 2017). These traits were stated back in 2011 by Panesar et al as they also suggested that the non-technical traits such as better teamwork, and communication in the operating theatres reduces risk, improves staff well-being and mental health, reduces staff turnover, and reduces delays and glitches in the surgical process which is key to a safe working environment.

Speaking up and being encouraged to do so is not easy as Oppikofer and Schwappach (2017) suggested that nurses for example may not speak up to a surgeon if they notice a problem due to fear of being ridiculed for perhaps being incorrect, or the fear of being blamed by a superior. Encouragement of speaking up and creating a climate allowing all members to speak without the risk of being punished is therefore a true act of medical leadership. During surgery, all team members must be empowered to stop the surgery if they sense or discover a breach in patient safety.

After the publication of the first global survey on the use of the SSC by Haynes et al 2009, it was clear that this tool, adopted from the aviation industry would have an increasing impact on patient safety. High Quality Care For All (2008) proposed that a never event policy be introduced for the NHS in England from April 2009. The NPSA co-produced a set of criteria for defining “never events” and agreed a core list of eight “never events”, alongside a policy framework.

Regarding the surgical intra operative never events, only two were defined in 2009, they were wrong site surgery and retained instrument post operation. A new list of never events for 2011/12 increased to twenty-five. This included the other current surgical intra-operative never event, classed as wrong implant/prostheses. Retained instrument post operation was changed to retained foreign object post-operation. (DOH 2011).

At the time of writing this paper there were a total of 223 NHS trusts in England and 157 trusts have operating theatres. (NHS England, facilities data, Q3 2019-20). This equates to 3,282 operating theatres where a never event may occur.

A question to consider is has the NHS created a stigma instead of learning from ones’ mistake? Never events highlight weak areas within an organisation’s safety process and patient safety. Therefore, they are integral for the improvement and development of the NHS system. (Sampson, 2018). By creating a list of never events, not only is the NHS suggesting that other equally harmful events are not as serious as they have not made it onto the list, but it can also attach a stigma to these events and creates a culture of blame as opposed to a culture of learning and openness (MDU, 2016). From April 2016, patient safety was now part of NHS Improvement and for transparency about patient safety incident reporting, from April 2014, the NHS published never event data (NHS England, 2016). Sampson (2018) summed up healthcare mistakes by stating that at any point during patient treatment, a mistake can occur, these often come down to human error, we should learn from our mistakes, but sometimes they are unavoidable, and therefore should be seen as a learning curve as opposed to a disastrous event for the trust. Figure 1 on page ** details the amount of intra operative never events that have occurred between April 2012 and March 2020

Figure 1 – Never event final data, April 2012 – March 2020 (excluding wrong tooth removed)

The three intra-operative never events, wrong site surgery, retained foreign object post procedure and wrong implant/prostheses will be briefly summed up.

Wrong site surgery (WSS)

From April 2012 – February 2021, 942 cases were reported to NHS England. (NB. The total figure excludes wrong tooth removal). World-wide, approximately 2,700 patients are harmed by WSS each year with communication breakdowns reported as the main cause of such errors. (Collins et al, 2014). Wrong site surgery (WSS) is potentially devastating, and it is still a concern in orthopaedic surgery, despite major initiatives to address this issue such as “operate through your initials” campaign by the Canadian Orthopaedic Association (Wright et al 2009 , the “sign your site” initiative by the AAOS (2009), the “SMaX” imitative (NASS, 2001) and the Royal College of surgeons and NPSA guidance (2009).

The Care Quality Commission (CQC) review in 2018, ‘Opening the door to change’ suggested that WSS occurs due to:

  1. Corporate culture and insufficient emphasis on adherence to SOPs.
  2. Task overload and time pressure.
  3. Distractions.
  4. Absence of cross-checking or team co-ordination.
  5. Complacency and over confidence.
  6. Doing checklist as ‘tickbox’.
  7. Changing team e.g., a new surgeon taking over shift or different surgeons from the one taking consent.
  8. Missing patient notes.
  9. Similar sounding first names.

Since February 2021, wrong tooth extraction was no longer considered a never event. (BDA, 2021 and NHS Improvement, 2021) NHS improvement came to this decision due to the systemic barriers to prevent the removal of wrong teeth are considered not to be strong enough to prevent these from occurring e.g., lack of standardisation in types of tooth notation and difficulties with site marking (NHS Improvement, 2021). Is this correct or just a way of reducing reporting? Is wrong tooth removal as harmful or as dangerous as potentially life-threatening events such as maternal death or surgery on the wrong side of the brain? (Sampson, 2018).

Retained foreign object post procedure

Data between 1st April 2015 to 31st March 2020 reveals that 389 claims were settled, with damages paid, for retained foreign objects post-surgery. These were classed as never events. This cost the NHS £12,472,347 (NHS Resolution, March 2021). The most common retained foreign object post procedure was instruments (46%) followed by swabs (44%). From April 2012 – February 2021 a total of 860 incidents were reported to NHS England (NHS England, 2021). Studies by Wang et al (2007), Zejnullahu et al (2017) and Zarenhad et al (2017) all stated that patients may re-present with the following symptoms following a retained foreign object (swab) frequent infections; palpable mass; obstruction; abscess and pain. Zejnullahu et al (2017) study concluded by stating that the key to preventing the incidence of retained surgical bodes is excellent communication with the surgical team, between the surgeons, nurses, and anaesthetists.

A study by Steelman et al (2018) in the USA reported a total of 319 incidents involving retained sponges between 2012-2017. These were most frequently retained in the abdomen or pelvis (50.2%) and the vagina (23.9%). NHS England during the same time reported 341 swabs or similar items. Steelman et al (2018) concluded that the contributing factors which led to retained foreign objects included human factors, leadership, communication, and the environment. Interesting to note that Gawande (2003) stated that in most cases where sponges were left behind, the number of sponges before closing was always declared correct, suggesting that counting alone is not sufficient. In addition, Stawicki et al (2013) suggested that studies have showed that body mass index, intraoperative complications and unexpected events are associated with an increased risk for retained foreign bodies after surgical procedures.

Wrong implant/prosthesis

The data from April 2012 – March 2020 shows that ophthalmic lens was the largest wrong implant (n=166), followed by hip prosthesis (n=93) and then knee prosthesis (n=90). In 2015, NHS England published the National Safety Standards for Invasive Procedures (NATSSIPS). One of the standards relates to prosthesis verification and details the expected checks to be carried by the theatre team, The checks include, type, design, style or material, side, manufacturer, expiry date, sterility, and compatibility of multiple components. It is important to note, regarding both hip and knee arthroplasty, that there are an estimated 80,000 prosthesis and implant combinations that could be used during surgery (HSIB, 2018).


To conclude, Barimani (2020) found no evidence to suggest that any patient harm has occurred by using the SSC. However, for checklists to work, be successful and to reduce harm, non-technical skills such as leadership, basic cognition, situational awareness, operative briefing, and communication all need to be taught and understood by all users. There is still much work needed to address the myth of having the time to perform the checklist, but this can be overcome by having local champions to help reduce the perceived associated barriers of using the safe surgery checklist. Having tailored speciality specific checklists that are reviewed every two years to ensure that are still meeting the needs of both the patient and the end users may also increase staff buy-in. There is still much more research needed to understand if these contributing factors result in patient harm, as well as understanding if a further second time out would be of benefit.






[1] AMERICAN ACADEMY OF ORTHOPAEDIC SURGEONS. Advisory statement; wrong-site surgery. AAOS;2009 [Accessed 4th April 2011]

[2] BABU, A., LEVISON, A. Effective implementation of WHO surgical safety checklist. British journal of anaesthesia. 2012. 108 (1210.0) ii33-ii34.

[3] BARBANTI-BRODANO, G., GRIFFONI, C., HALME, J., TEDESCO, G., TERZI, S., BANDIERA, S., GHERMANDI, R., EVANGELISTI, G., GIROLAMI, M., PIPOLA, V., GASBARRINI, A., FALAVIGNA, A. Spinal surgery complications: an unsolved problem—Is the World Health Organization Safety Surgical Checklist an useful tool to reduce them? European Spine Journal, 2020. 29 (5) 927-936

[4]BARIMANI, B., AHANGAR, P., NANDRA, R., PORTER, K. The WHO Surgical Safety Checklist: A Review of Outcomes and Implementation Strategies. Perioperative Care and Operating Room Management, 2020. 21.

[5] BERGS, J., LAMBRECHTS, F., SIMONS, P., ET AL. Barriers and facilitators related to the evidence a systematic review of the qualitative implementation of surgical safety checklists. BMJ Qual Saf, 2015.

[6] BRAHAM, D., L., RICHARDSON, A., L., MALIK, I., S. Application of the WHO surgical safety checklist outside the operating theatre: medicine can learn from surgery. Clin Med, 2014. 14:468-474.

[7] BRITISH DENTAL ASSOCIATION 2021. Wrong tooth extraction removed from never evets list [Accessed 28th August 2021].

[8] CALLAND, J., TURRENTINE, F., GUERLAIN, S. The surgical safety checklist: lessons learned during implementation. Am Surg, 2011. 77 (9) 1131-1137.

[9] CARE QUALITY COMISSION. Opening the door to change. NHS Safety culture and the need for transformation.

[Accessed 16th September 2021].

[10] CLARK, S., C., DUNNING, J., ALFIERI, O., R., ELIA, S., HAMILTON, L., R., KAPPETEIN, P., A., LOCKOWANDT, U., SARRIS, G., E., KOLH, P,.H. EACTS guidelines for the use of patient safety checklists. European Journal of Cardio-thoracic Surgery, 2012. 41 (5) 993-1004.

[11] COLLINS, S., J., NEWHOUSE, R., PORTER, J., TALSMA, A. Effectiveness of the surgical safety checklist in correcting errors: A literature review applying reasons Swiss cheeses model. AORN journal, 2014. 100 (1) 65-79.

[12] CONLEY, D.M., SINGER, S.J., EDMONDSON, L. Effective surgical safety checklist implementation. Journal of American college of surgeons. 2011. 212 (5) 873-879.

[13] CRAIG, R., MOXLEY, L., YOUNG, D., SPENCELEY, N., S., DAVIDSON, M., G. Strengthening handover communication in pediatric cardiac intensive care. Paediatric Anaesthesia 2012. 22: 393-399.

[14] DEGANI, A., WIENER, E. L., Cockpit checklists: Concepts, design, and use.Human factors, 1993. 360: 491-499.

[15] DE VIRIES, E., N., RAMRATTAN, M., A., SMORENBURG, S., M., GOUMA, D., J., BOERMEESTER, M., A. The incidence and nature of in-hospital adverse events: a systematic review.

Qual. Saf. Health Care, 2008. 17 (3) 216-223.

[16] DINDO, D., CLAVIEN, P., A. What is a surgical complication? World J Surg, 2008. 32: 939-941.

[17] FLIN, R., MITCHELL, L., 2008. Safer surgery: Analysing behaviour in the operating theatre (EDS) Aldershot, Ashgate.

[18] FOURCADE, A., BLACHE, J.L., GRENIER, C. Barriers to staff adoption of a surgical safety checklist. British medical journal quality and safety. 2012. 21 (3) 191-197.

[19] GAWANDE, A., A. STUDDERT, D., M., ORAV, E., J., BRENNAN, T., A., ZINNER, M., J. Risk factors for retained instruments and sponges after surgery. N Engl J Med, 2003. 348 (3) 229-235.

[20] GEORGIOU, E., MASHINI, M., PANAYIOTOU, I., EFSTATHIOU, G., EFSTATHIOU, C.I., CHARALAMBOUS, M., IRAKLEOUS, I. Barriers and facilitators for implementing the WHO’s safety surgical checklist: A focus group study among nurses. Journal of perioperative practice, 2018. 28 (12) 2339-346.

[21] GILLESPIE, B., M., MARSHALL, A. Implementation of safety checklists in surgery: a realist synthesis of evidence. Implementation sciences, 2015. 10:137.

[22] GILLESPIE, B., M., CHABOYER, W., WALLIS, M., FENWICK, C. Why isn’t ‘time-out’ being implemented? An exploratory study. Quality and safety in healthcare. 2010. 19 (2) 103-106.

[23] GILLESPIE, B., CHABOYER, W., LONGBOTTOM, P., WALLIS, M. The impact of organisational and individual factors on team communication in surgery: a qualitative study. Int J Nurs Stud, 2010. 47:732-741.

[24] GILLESPIE, B., M., HARBECK, E., L., LAVIN, J., HAMILTON, K., GARDINER, T., WITHERS, T., K., MARSHALL, A., P. Evaluation of a patient safety programme on Surgical Safety Checklist Compliance: a prospective longitudinal study. BMJ open quality, 2018. 7 (3) e000362.

[25] GAWANDE, A. The checklist: if something so simple can transform intensive care, what else can it do? New Yorker, 2007. 86-101.

[26] HARDEN, S.W. Six things every plastic surgeon needs to know about teamwork training and checklists. Aesthet Surg J. 2013. 33:443-448.

[27] HAYES, C. Surgical safety checklist: improved patient safety through effective teamwork. Healthcare Quarterly, 2012. 15 (1) 57-62.

[28] HAYNES, A.B., WEISER, T.G., BERRY, W.R., LIPSITZ, S.R, BREIZAT. A- HS, ET AL. A surgical safety checklist to reduce morbidity and mortality in a global population. N England Journal of Medicine. 20009. 360 (5),491-9.

[29] HAYNES, A.B., WEISER, T.G., BERRY , W.R., LIPSITZ, S.R., BREIZAT, A.H., DELLINGER, E.P. et al/ Changes in safety attitude and relationship to decreased postoperative morbidity and mortality following implementation of a checklist-based surgical safety intervention. BMJ quality and safety, 2011. 20 (1), 102-107

[30] HEALTHCARE SAFETY INVESTIGATION BRANCH. Investigation into the implantation of wrong prosthesis during joint replacement surgery [Accessed 20th September 2021].

[31] HELMREICH, R.L. 2000. Human factors aspects of the air Ontario crash at Dryden. Toronto, ON: Minister of supply and services.

[32] HELMREICH, R., L. On error management: lessons from aviation. BMJ, 2000. 320 (7237) 781.

[33] HU, Y., Y., ARRIAGA, A., F., PEYRE, S., E., CORSO, K., A., ROTH, E., M., GREENBERG, .C., C. Deconstructing intraoperative communication failures. J Surg Res, 2012. 177 (1) 37-42.

[34] HURLBERT, S., N., GARRETT, J. Improving operating room safety. Safety in surgery, 2009. 3 (1) 25.

[35] HURTADO, J., J., JIMENEZ, X., PENALONZO, M., VILLATORO, C., DE IZQUIERDO, S., CIFUENTES, M. Acceptance of the WHO surgical safety checklist among surgical personnel in hospitals in Guatemala City. BMC Health Serv. Res. 2012, 12 91) 169.

[36] INSTITUTE OF MEDICINE(IOM) 2001. Crossing the quality chasm. A new health system for the 21st century. Washington DC: National Academy Press.

[37] JOY, B., F., ELLIOTT, E., HARDY, C., SULLIVAN, C., BACKER, C., L., KANE., J., M. Standardized multidisciplinary protocol improves handover of cardiac surgery patients to the intensive care unit. Pediatr Crit Care Med, 2011. 12: 304-308.

[38] KELLY, S., P., STEEPLES, L., R., SMITH, R., AZUARA-BLANCO, A. Surgical checklist for cataract surgery: progress with the initiative by the Royal college of Ophthalmologists to improve patient safety. Eye, 2013. 27 (7) 878-882.

[39] KHAN, I., CHANGEZ, H., OWNES, D., MCWILLIAMS, B. Can aviation style team training improve safety, quality, and efficiency in the operating theatre? Clinical Otolaryngology. 2012. 37: (F039) 27.

[40] LEAPE, L., L. Error in Medicine. Jama 1994. 272: 1851-1857.

[41] LEVY, S.M., SENTER., C.E., HAWKINS, R.B. Implementing a surgical checklist: more than checking a box. Surgery. 2012. 152(3), 331-336.

[42] LEWIS, G., H., VAITHIANATHAN, R., HOCKEY, P., M. ET AL. Counter heroism, common knowledge, and ergonomics: concepts from aviation that could improve patient safety. Milbank, 2011, 89 :4-38.

[43] LINGARD, L., REGEHR, G., ORSER, B. ET AL. Evaluation of a preoperative checklist and team briefing among surgeons, nurses and anaesthesiologists to reduce failures in communication.

Arch Surg, 2008. 143 (1) 12-17.


Communication failures in the operating room: an observational classification of recurrent types and effects. Qual Saf Health Care, 2004. 13 (5) 33-334.

[45] LOW, D., WALKER, I., HEITMILLER, E. Implementing checklists in the operating room. Paediatr Anaes, 2012. 22: 1025-1031.

[46] MAHAJAN, R., P. The WHO surgical checklist Best Practice and Research: Clinical Anaesthesiology, 2011. 25 (2) 161-168.

[47] MAINTHIA, R., LOCKNEY, T., ZOTOV, A., FRANCE, D., J., BENNETT, M., ST JACQUES, P., J., ET AL. Novel use of an electronic whiteboard in the operating room increases surgical team compliance with pre-incision safety practices. Surgery, 2012. 38 (6) 254-260.

[48] MAKARY, M., A., MUKHERJEE, A., SEXTON, J., B. ET AL. Operating room briefings and wrong-site surgery. J Am Coll Surg. 2007. 204 (2) 293-297.

[49] McCONNELL, D., J., FARGEN, K., M., MOCCO, J. Surgical checklists: a detailed review of their emergence, development, and relevance to neurosurgical practice. Surg Neurol Int, 2012. 3:2.

[50] MDU, 2016. Never events should be learned from alongside all patient incidents. The MDY 2016. Available at

[51] NATIONAL PATIENT SAFETY AGENCY, 2010. National Patient Safety Alert. Alert 0861.

National Patient Safety Agency, London, 2009.

[52]NHS, 2020. Never events reported as occurring between 1 April 2019 and 31 March 2020 – Final update. [Accessed 26th August 2021].

[53] NHS ENGLAND 2013. Never events data summary for 2012/2013. [Accessed 15th August 2021].

[54] NHS ENGLAND 2014. Never events reported as occurring between 1 April 2013 and 31 March 2014. [Accessed 15th August 2021].

[55] NHS ENGLAND 2015. Never events reported as occurring between 1 April 2014 and 31 March 2015. [Accessed 26th August 2021].

[56] NHS ENGLAND 2015. National Safety Standards for Invasive Procedures

[Accessed 6th October 2021].

[57] NHS ENGLAND 2016. Health and high-quality care for all, now and for future generations.

Never events data.

[Accessed 15th August 2021].

[58] NHS ENGLAND 2021. Patient safety [Accessed 15th August 2021].

[59] NHS ENGLAND AND IMPROVEMENT 2019. Never events reported as occurring between 1 April 2017 and 31 March 2018 – Final update. [Accessed 26th August 2021].

[60] NHS ENGLAND, 2019-20. Supporting facilities data, operating theatres in NHS organisations in England, quarter 3 2019-20. [Accessed 26th August 2021].

[61] NHS ENGLAND, 1 APRIL 2020 – 28 FEBRUARY 2021. Provisional publication of never event data reported as occurring 01 April 2020 – 28 February 2021. [Accessed 4th September 2021].

[62] NHS IMPROVEMENT, 2017. Never events reported as occurring between 1 April 2015 and 31 March 2016 – Final update. content/uploads/2020/08/NE_data_report_1_April_2015_-_31_March_2016_FINAL_v2.pdf [Accessed 26th August 2021].

[63] NHS IMPROVEMENT, 2018. Never events reported as occurring between 1 April 2016 and 31 March 2017 – Final update. [Accessed 26th August 2021].

[64] NHS IMPROVEMENT, 2021. Never Events list 2018, first published January 2018 (Last updated February 2021) [Accessed 28th August 2021].

[65] NORTH AMERICAN SPINE SOCIETY. Prevention of wrong site surgery: sign, mark and x-ray (SmAX). LaGrange, IL: North American Spine Society, 2001, NASS;2001 [Accessed 4th August 2021].

[66] NORTON, E., RANGEL, S. Implementing a pediatric surgical safety checklist in the OR and beyond

Aorn J, 2011. 94: 950-958.

[67] OAK, S., N., DAVE, N., M., GARASIA, M., B., PARELKAR, S., V. Surgical checklist application and its impact on patient safety in pediatric surgery. Journal of postgraduate medicine, 2015. 61 (2) 92-94.

[68] O’CONNOR, P., REDDIN, C., O’SULLIVAN, M., O’DUFFY, F., KEOGH, I. Surgical checklists: The human factor. Patient Safety in Surgery, 2013. 7 (1).

[69] O’CONNOR, P., KEOGH, I., AZUARA-BLANCO, A. Teamwork and communication. In: enhancing surgical performance: a primer in non-technical skills. 2015. 105-121.

[70] O’DOWD, A. NHS Waiting list hits 14-year record high of 4.7million people. [Accessed 24th August 2021]. BMJ, 2021. 373: n995.

[71] OPPIKOFER, C., SCHWAPPACH, D. The Role of Checklists and Human Factors for Improved Patient Safety in Plastic Surgery. Plastic and reconstructive journal, 2017. 140 (6) 812e-817e.

[72] PANESAR, S.S, CLEARY, K., SHEIKH, A., DONALDSON, L. The WHO checklist: a global tool to prevent errors in surgery. Patient safety in surgery, 2009, 3:9.

[73] PANESAR, S., S., NOBLE, D., J., MIRZA, S., B., PATEL, B., MANN, B., EMERTON, M., CLEARLY, K., SHEIKH, A., BHANDARI, M. Can the surgical checklist reduce the risk of wrong site surgery in orthopaedics? –Can the checklist help? Supporting evidence from analysis of a national patient incident reporting system. Journal of orthopaedic surgery and research, 2011. 6:18.

[74] PATEL, J., AHMED, K., GURU, K., A., KHAN, F., MARSH, H., KHAN, M., S., DASGUPTA, P. An overview of the use and implementation of checklists in surgical specialities – A systematic review. International Journal of Surgery, 2014. 12 (12) 1317 – 1323.

[75] PAULL, D.E., MAZZIA, L.M, IZU, B.S., NEILY, J., MILLS, P.D., BAGIAN, J.P. Predictors of successful implementation of preoperative briefings and postoperative debriefings after medical team training. American journal of surgery 2009. 198 (5) 675-678.

[76] PETROU, N., GODDEN, A., RIMMER, S., PISAREK, C., KEOGH, G., HADJIMINAS, D., AL-MUFT, D. A “breast specific” WHO checklist-Improving safety for breast cancer patients. European Journal of Surgical Oncology, 2016. 42 (5)S30.

[77] PUGEL, A., E., SIMIANU, V., V. FLUM, D., R., PATCHEN DELLINGER, E. Use of the surgical safety checklist to improve communication and reduce complications. Journal of Infection and Public Health, 2015. 8 (3) 219-225.

[78] RAMAN, J., LEVESON, N., SAMOST, A., L., DOBRILOVIC, N., OLDHAM, M., DEKKER, S., FINKELSTEIN, S. When a checklist is not enough: How to improve them and what else is needed. The Journal of thoracic and cardiovascular surgery, 2016. 152 (2) 585-592.

[79] REED, S., GANYANI, R., KING, R., PANDIT, M. Does a novel method of delivering the safe surgical checklist improve compliance? A closed loop audit. International journal of surgery, 2016. 32: 99-108.

[80] REID, J. VINCENT, C. Towards safer surgery. Association for perioperative practice, 2016. 26 (12) 260-261.

[81] REINERTSEN, J.L., GOSFIELD, A.G., RUPP, W., WHITTINGTON, J., W. 2007. Engaging physicians in a shared quality agenda. (IHI innovation series white paper) Cambridge, MA: Institute for healthcare improvement.

[82] RYDENFALT, C., EK, A., LARSSON, P., A. Safety checklist compliance and a false sense of safety: new directions for research. BMJ Qual. Saf. 2014. 23 (3) 183-186.

[83] SAMPSON, V. Should wrong extraction site be classed as a never event? British Dental Journal, 2018. 224 94) 291 – 292.

[84] SCHWAB, K. 2017. The fourth industrial revolution. London, UK, Penguin.

[85] SEWELL, M., ADEBIBE, M., JAYAKUMAR, A. ET AL. Use of the WHO surgical safety checklist in trauma and orthopaedic patients. Int orthop, 2011. 35 (6) 897-901.

[86] SIVATHASAN, N., RAKOWSKI, K.R., ROBERTSON, B.F., VIJAYARAJAN, L. The world health organization’s surgical safety checklist: should evidence based initiatives be enforced in hospital policy?

Journal of royal society of medicine short reports. 2010. 1 (5) 40.

[87] SMITH, E., A., AKUSOBA, I., SABOL, D., M., STAWICKI, S., P., GRANSON, M., A., ELLISON, E., C. Surgical safety checklist: Productive, nondisruptive, and the “right thing to do”. Journal of Postgraduate Medicine, 2015. 61 (3) 214-215.

[88] SONG, J., B., VEMANA, G., MOBLEY, J., M., BHAYANI, S., B. The second “time-out” : A surgical safety checklist for lengthy robotic surgeries. Patient safety in Surgery, 2013. 7 (1) 19.

[89] STAHEL, P.F., SABEL, A., L., VICTOROFF, M., S. ET AL. Wrong-site and Wrong-patient procedures in the universal protocol era: analysis of a prospective database of physician self-reported occurrences. Arch surg. 2010. 145 (10) 978-984.

[90] STAWICKI, S., P., MOFATT-BRUCE, S., D., AHMED, H., M., ANDERSON, H., L., BALIJA, T., M., BERNESCU, I., ET AL. Retained surgical items: a problem yet to be solved. J Am Coll Surg, 2013. 216 (1) 15 – 22.

[91] STEELMAN, V., M., SHAW, C., SHINE, L., HARDY-FAIRBANKS, J. Retained surgical sponges: a descriptive study of 319 occurrences and contributing factors from 2012 – 2017. Patient safety in surgery, 2018. 12:20.

[92] SYSTEMS APPROACH, 2012. Agency for healthcare research and quality. [Accessed January 2014].

[93] TAKALA, R., S., K., K., PAUNIAHO, S., L., KOTKANSALO, A., ET AL. A pilot study of the implementation of WHO surgical safety checklist in Finland: improvements in activities and communication. Acta Anaesthesiol. Scand, 2011. 55 (10) 1206-1214.

[94]TANNER, L. 2013. Associated press FDA takes fresh look at robotic surgery-the high tech helper da vinci is under scrutiny after reports of problems. [Accessed February 2014].

[95] TAYLOR, B.A., SLATER, A., REZNICK, R. The surgical safety checklist effects are sustained, and team culture is strengthened. The surgeons, 2010. 8 (1) 1-4.

[96] THIMBLEBY, H. Technology and the future of healthcare. J Public Health Res, 2013. 2:e28.

[97[ THOMAS, E., J., STUDDERT, D., M., BURSTIN, H., R., ET AL. Incidence and types of adverse events and negligent care in Utah and Colorado. Med. Care, 2000. 38 (3) 261-271.

[98] TIAN, T., MYERS, L., BRAY, A., DE BERKER, D. The WHO surgical checklist: Patterns compliance in an UK dermatology regional referral centre. Journal of Investigative Dermatology. 2015. 135, S37.

[99] TIAN, T., MYERS, L., BRAY, A., BOGUCKI, P., DE BERKER, D. WHO surgical checklist in dermatology: compliance, attitudes & barriers. Journal of Investigative Dermatology. 2016. 136 (9) S163.

[100] TIAN, T., MYERS, L., BOGUCKI, P., BRAY, A., DE BERKER, D. World health organization surgical checklist in dermatological surgery: compliance, attitudes, and barriers. British Journal of Dermatology. 2016. 175 (S1) 116-117.

[101 TREADWELL, J., R., LUCASR, S., TSOU, A., Y. Surgical checklists: a systematic review of impacts and implementation. BMJ quality and safety, 2014. 23 (4) 299-318

[102] TUCKER, A., L., SPEARS, S., J. Operational failures and interruptions in hospital nursing.

Health services research, 2006. 250 (6) 1034-1040.

[103] URBACH, D., R., GOVINDARAJAN, A., SASKIN, R., WILTON, A., S., BAXTER, N., N. Introduction of surgical safety checklists in Ontario, Canada. N Engl J Med. 2014. 370:1029-1028.

[104] VAN KLEI, W.A, HOFF, R.G., VAN AARNHEM, E., E., H., L., SIMMERMACHER, R., K., K., J., REGLI, L., P., P., E., et al. Effects of the introduction of the WHO “Surgical Safety Checklist” on in-hospital mortality. Annals of surgery,2012. 255 (1) 44-49.

[105] VATS, A., VINCENT, C.A., NAGPAL, K., DAVIES, R.W., DARZI, A., MOORTHY, K. Practical challenges of introducing WHO surgical checklist. UK pilot experience. BMJ, 2010. 340: b5433.

[106] VATS, A., VINCENT, C.A., NAGPAL, K., DAVIES, R.W., DARZI, A., MOORTHY, K. Practical challenges of introducing WHO surgical checklist. UK pilot experience. BMJ online, 2010. 340 (7738) 133-135.

[107] VERDAASDONK, E.G., STASSEN, L., P., WIDHIASMARA, P., P., DANKELMAN, J. Requirements for the design and implementation of checklists for surgical process. Surg Endosc 2009. 23: 715-726.

[108] VISWANTH, A., BALINT, A., JOHNSON, R.E., ROSENBERG, M.B., OREADI, D. Surgical safety checklists are under utilised in ambulatory oral and maxillofacial surgery. Journal or oral and maxillofacial surgery. 2017, 07, 154.

[109] VOGTS, N., HANNAM, J., A., MERRY, A., F. ET AL. Compliance and quality in administration of a surgical safety checklist in a tertiary New Zealand hospital. N Z Med J, 2011. 124: 48-58.

[110] WANG, C., F., CIPOLLA, J., SEAMON, M., J., LINDSEY, D., E., STAWICKI, S., P. Gastrointestinal complications related to retained surgical foreign bodies (RSFB): A concise review.

OPUS, 2007. 12: 11-8.

[111] WESTMAN, M., TAKALA, R., RAHI, M., IKONEN, T., S. The Need for Surgical Safety Checklists in Neurosurgery Now and in the Future–A Systematic Review. World Neurosurgery, 2020. 134: 614-628.e3.

[112] WORLD HEALTH ORGANIATION 2008. Implementation manual WHO surgical safety checklist: safe surgery saves lives. Geneva, WHO.

[113] WORLD HEALTH ORGANIATION 2008. World alliance for patient safety. WHO guidelines for safe surgery. Geneva.

[114] WORLD HEALTH ORGANIATION 2008. Implementation of the surgical safety checklist. WHO, 2008, 1-28.

[115] WORLD HEALTH ORGANISATION, 2009. WHO Surgical safety checklist [Accessed May 12, 2017].

[116] WORLD HEALTH ORGANISATION, 2009. WHO Surgical safety checklist implementation [Accessed 22nd August 2021].

[117] WORLD HEALTH ORGANISATION 2009. Patient safety. WHO guidelines for safe surgery 2009. Switzerland. Available at [Accessed 15th August 2021].

[118] WRIGHT, P., H., BURNABY, B., C. 2009. Committee on Orthopaedic Practice and Economics (COPE). Position paper on wrong sided surgery in orthopaedics. Prepared for the Canadian orthopaedic association June 1994, COA-AC) 1994. http://coa-aco/library/health-policy/wrong-sided/surgery-in-orthopaedics.html [ Accessed 4th April 2011].

[119] ZARENEZHAD, M., GHOLAMZADEH, S., HEDJAZI, A., SOLTANI, K., GHAREDAGHI, J., GHADIPASHA, M., HOSSEINI, S., M., V., ZARE, A. Three years evaluation of retained foreign bodies after surgery in Iran. Annals of Medicine and Surgery, 2017. 15: 22-25.

[120] ZEJNULLAHU, V., A., BICAJ, B., X., ZEJNULLAHU, V., A., HAMZA, A., R. Retained surgical foreign bodies after surgery. Open access Macedonian Journal of Medical Sciences, 2017. 5 (1) 97-100.

Appendix one – Synthesised framework on the safer surgical checklist

Why use checklists The operating theatre is reportedly the most common site for adverse events to occur (Leape, 1994) Commonly used as a method to minimise risk (Helmreich, 2000) Surgical procedures pose a considerable risk (Thomas et al, 2000) Checklist based on three principles, simplicity, widespread applicability, and measurability (WHO, 2008) Misuse of checklists are a major contributor to accidents or serious incidents (Dindo & Clavien, 2008) Reduced preventable post-operative complications (Haynes et al, 2009) Reduce the risk of morbidity, mortality, and surgical site infection (Haynes et al, 2009) Tool to prevent errors in surgery (Panesar et al, 2009) This tool would have an increasing impact on patient safety (Haynes et al, 2009) Perceived improvement in communication, teamwork, and respect (Taylor et al, 2010) Operating room staff more aware of issues relating to patient safety (Takala et al, 2011) Challenge and response (Lewis et al, 2011) Increase in teamwork and safety climate (Haynes et al, 2011) Reinforces teamwork and contributes to effective communication (McConnell et al, 2012) Safety tool to improve communication (Gillespie, 2010 & Low et al, 2012) Enhance teamwork and improve handover (Van Kiel, 2012) Improved team dynamics (Hayes, 2012) Reduction in complications, surgical site infections and death (Tanner 2013) Decrease in surgical morbidity and mortality (Pugel et al, 2015) May prevent active and latent failures (Collins et al, 2014) Cognitive aid (O’Connor et al, 2015) Detecting instances of human error and equipment malfunctions (Oak et al, 2015) Help operating room team members remember important details (Pugel et al, 2015) Surgery high source of preventable adverse events (Reid, 2016) Reduce morbidity, mortality and improve teamwork (Tian, 2016) Aim of preventing unnecessary death and improve outcomes (Viswanath et al, 2017) Fatigue related errors (HSIB, 2019)

Why use checklists (Continued) Useful, simple, and cost effective in enhancing communication and patient safety (Westman et al, 2020) Improvement in outcomes for patients (Barimani et al, 2020) No evidence to suggest harm by surgical checklist use (Barimani, 2020) Tool to enhance surgical safety (Barimani et al, 2020)
Barriers Perception that a briefing would slow down progress (Hulbert & Garrett, 2009) WHO checklist caused unnecessary delay (Sewell et al, 2011) WHO checklist takes only about two minutes on average (Taylor et al, 2010) Hierachy, timing, perception of duplication and relevance (Vats et al, 2010) Time constraints during emergencies (Sivathasan et al, 2010 and Van Kiel et al, 2012) Knowledge of when to use (Hurtado et al, 2012) Lack of understanding and familiarity (Levy et al, 2012) Responsibility for the checklist (Clarke et al, 2012) Create unnecessary patient anxiety (Fourcade et al, 2012) Unimportant or a waste of time, too long to complete (Fourcade et al, 2012) Causes delays and cancellations due to no time being available (Hayes, 2012) Requirements for signatures, lack of time and assertiveness of staff (O’Connor et al, 2013) Inconvenience during emergency cases (Treadwell et al, 2014) Creates an unnecessary delay (Urbach et al, 2014) Checklist decreased operating room efficiency (Treadwell et al, 2014) Surgeons’ resistance to changing habits, awkwardness, and hierarchy (Treadwell et al, 2014) Further work is needed to understand staff attitudes and barriers (Tian et al, 2015) Provide time for checklist completion can increase ‘buy in’ (Tian et al, 2016) Adequate time must be provided for checklist completion (Tian et al, 2016) Significant barriers were workflow, limited knowledge, contents, lack of clinical leadership and dissonant attitudes (Gillespie et al, 2018) Resistance to implementation of the safer surgery checklist by some members of the surgical team (Georgiou et al, 2018) Lack of a streamlined and cohesive approach in implementation (Barimani et al, 2020)
Culture Unlikely to be implemented or maintained without senior leadership (Degani & Wiener, 1993) Alter approach to current safety culture and behaviours (Flin & Mitchell, 2008) Primary challenge (Mahajan, 2011) Will require a change in culture (Mahajan, 2011) Safer surgery checklist could promote a shift in them operating room culture (Sewell et al, 2011) Need to consume only minimal resources (Clarke et al, 2012) Evolving cultural awareness (Kelly et al, 2013) Communication between hospital leadership and front-line practitioners must be open, honest, and constructive (Smith et al, 2015) Time to amend the delivery of the safer surgical checklist to enhance compliance (Reed et al, 2016) Healthcare personnel struggle to cope with culture, resource’s and systems (CQC, 2018)
Training Importance of education and training in changing staff perceptions (Sewell et al, 2011) Three essential elements, developing local champions, organisational leadership, and training (Mahajan, 2011) CRM training (Khan et al, 2012) Without proper instruction, it may become a nuisance (Pugel et al, 2015) On-going education programme (Gillespie et al, 2018)
Non-technical skills Leadership for the successful implementation of the safer surgical checklist is key (Conley et al, 2011) Non-technical skills are shown to improve patient outcomes (Joy et al, 2011) Non-technical traits reduce risk (Panesar et al, 2011) Theatre safety can be made more effective by introducing models of non-technical training (Khan et al, 2012) Introduction of the safer surgical checklist will require strong leadership (Clarke et al, 2012) Communication errors are the most common cause of adverse events (Craig et al, 2012) Adverse patient outcomes are frequently due to sub-standard non-technical skills (Patel et al, 2014) Support of hospital leadership is essential (Oppikofer and Schwappach, 2017) Teamwork, leadership, situational awareness, decision making, task management and communication have long been neglected (Oppikofer and Schwappach, 2017) Promoting teamwork, communication and managing workload (Sampson, 2018)
Local Champions Having champions, especially anaesthesia and surgery are likely to influence peers (Reinertsen et al, 2007 & Paull et al, 2009) Important consideration to implementation is having local champions (NPSA, 2010) Local champions can lead implementation (Lingard et al, 2008 & Conley et al, 2011) Without champions to lead the change, the process becomes more difficult (Hulbert & Garrett, 2009) By using local champions, they achieved complete adoption (Vats et al, 2010) Will remove barriers and ensure the surgical safety checklist is used (O’Connor et al, 2013) Enlisting leaders as local champions is a positive strategy (Treadwell et al, 2014)
SSC Per speciality If modified, may influence its efficiency (Verdaasdonk et al, 2009) Adapted checklists to their context (Norton and Rangel, 2010 & Calland et al, 2011 & Mainthia et al, 2012) Should remain succinct and concise (McConnell et al, 2012) Tailored for different procedures (Thimbleby, 2013) Customised to fit local practice (Harden, 2013) Checklist design to improve behaviours (Rydenfalt et al, 2014) Encourage customization (Pugel et al, 2015) Prospectively tailored to the context (Gillespie and Marshall, 2015) Checklists for specialised surgical procedures (Raman et al, 2016) Tailored to the specific task being performed (Raman et al, 2016) Specific checklists may improve safety (Petrou et al, 2016)
Intra Operative Never Events Higher levels of communication and collaboration have a decreased risk of wrong site surgery (Makary et al, 2007) Sign-out is often low because this section is not explicitly linked to a specific event (Vogts et al, 2011) Most clinical errors of wrong site surgery result from the lack of communication (Stahel et al, 2010 & Panesar et al, 2011) Wrong site surgery represented a devastating event for all parties (Panesar et al, 2011) Main pitfall of the completion of the safer surgery checklist seemed to be the sign-out (Babu & Levison, 2012) Communication failures are common (Lingard et al, 2004 & Hu et al, 2012) Intra Operative Never Events (Continued) Creating an environment in which staff are not reprimanded, is vital to providing a safe patient care environment (Collins et al, 2014) Communication breakdowns reported as the main cause (Collins et al, 2014) Creating a culture of blame as opposed to a culture of learning and openness (MDU, 2016) The systems in place to create a safe environment are not impervious to human error (Zejnullahu et al, 2017) Key to preventing incidences is excellent communication (Zejnullahu et al, 2017) Contributing factors to retained foreign objects include human factors, leadership, communication, and the environment (Steelman et al, 2018) Should be seen as a learning curve as opposed to a disastrous event (Sampson, 2018) Wrong site surgery is the most common never event (NHS Improvement, 2021)

Appendix 2 – PRISMA flow diagram – Surgical Checklist

Appendix 2 – PRISMA flow diagram – Surgical Checklist

CPOC and AoMRC Launch Shared Decision Making Animation for Patients

October 25, 2021

The Centre for Perioperative Care a group made up of nine health partners including the Royal Colleges of Anaesthetists, GPs, Surgeons, Nurses and Physicians with the Academy of Medical Royal Colleges have launched a Shared Decision Making (SDM) animation for patients. The animation uses an example of ‘Peter’ to illustrate what SDM is, how it should be carried out effectively, what patients should consider and the thread of patient choice that should run through any patients care.

Shared decision making is a process in which clinicians and patients work together to select tests, treatments, management or support packages, based on clinical evidence and the patient’s informed preferences.

Patients who are effectively involved in making decisions about their care have fewer regrets about treatment, better reported communication with their healthcare professionals, improved knowledge of their condition and treatment options, better adherence to the selected treatment and an overall better experience with improved satisfaction.

Dr Ramai Santhirapala, CPOC Shared Decision Making Workstream lead said:

“We are pleased to launch a joint venture between the Centre of Perioperative Care and Academy of Medical Royal Colleges. This animation promotes involving patients in healthcare choices through shared decision making. Whilst the context is perioperative care, the process and lessons are applicable to the wider healthcare remit. We hope you find it useful whether you are a patient or a healthcare professional.  Follow Peter on his journey to decide what’s best for him.”

Lawrence Mudford, Patient Representative for CPOC and cancer survivor:

“The relationship between healthcare team and patient is central to perioperative care. One brings the expertise and knowledge, based on data sets, research and training; the other is an expert of their own values, beliefs and expectations. Between them, goals, options and outcomes can be managed and explored. This is particularly important when weighing up the benefits of an operation or procedure and setting them against the known risks that will be present.

“Stories are powerful learning opportunities to reflect on outcomes of individual stages in a patient journey. But on their own, they are just ‘stories’. The insight comes from understanding the context, recognising the resulting lessons learnt, and then deciding how to embed these experiences to provide a better patient experience for all patients.”

Watch the video here: Peter’s journey: An Example of Shared Decision Making

Find out more on Shared Decision Making:

Prioritise Improvements to Imaging as NHS Recovers from Pandemic, Urges Ombudsman

August 4, 2021

The Parliamentary and Health Service Ombudsman (PHSO) has written to the Government urging it to prioritise improvements to NHS imaging services as part of the health sector’s recovery from the COVID-19 pandemic.

The letter highlights findings from the Ombudsman’s report that shows recurrent failings in the way X-rays and scans are reported on and followed up across NHS services.

The Parliamentary and Health Service Ombudsman (PHSO) has written to the Government urging it to prioritise improvements to NHS imaging services as part of the health sector's recovery from the COVID-19 pandemic.

PHSO’s casework shows the devastating impact these failings have had on patients and their families. In several cases, signs of cancer in X-rays and scans were not reported, which led to delayed diagnoses and poorer outcomes for the patients. In one case, an 18-month delay in diagnosing pancreatic cancer meant a patient missed out on getting earlier treatment that could have prolonged their life. In another case, a patient was not told that their cancer was terminal until it was too late for them to get their affairs in order and see their son before they died.

Another common failing was inefficient handovers between departments and services. Investigations also found that trusts did not learn from previous errors related to imaging, which meant they repeated the mistakes.

In his report, Ombudsman Rob Behrens stresses that failings related to imaging are found across the NHS, in both primary and secondary care services, and not solely in imaging departments. He calls on the Government to commit to a system-wide programme of improvements for more effective and timely management of X-rays and scans.

Ombudsman Rob Behrens, said:

‘X-ray and scan results are key to diagnosis and treatment for many people. Yet the failings outlined in this report show that without a concerted effort to improve imaging, patient safety continues to be at risk.

‘Now, as the NHS recovers from the devastating impact of the pandemic, we have a vital opportunity to learn from the failings and embed system-wide changes to improve imaging in the health service.

‘The evidence-led recommendations I have set out should be implemented swiftly, with collaboration across government and the health sector to strengthen the NHS’s recovery.’

For many of the 5 million people currently waiting for hospital treatment, imaging will be a crucial part of their care. Effective diagnosis will be an essential first step in tackling the backlog caused by the pandemic, further highlighting the need for rapid action on improvements.

Peter Walsh from the patient safety charity Action against Medical Accidents, said:

‘We very much welcome this report, which underlines the urgency of improving radiology services across the board, including recognition, reporting and acting on imaging results.

‘We see in our own work how vital diagnostic services are, and the awful effect on people’s lives when they go wrong. There have now been a raft of reports and recommendations about improving radiology services.

‘This is a major patient safety issue, and we need to see the various recommendations implemented as a matter of urgency.’

Lessons UK Healthcare Systems Can Learn from the Pandemic

June 17, 2021

New report from the Royal College of Anaesthetists

Effective workforce planning and investment, staff wellbeing, and increased critical care capacity remain vital to the recovery of the NHS

The Royal College of Anaesthetists has launched a report identifying 10 lessons the UK healthcare system can learn from the pandemic. The College is calling for the findings to be implemented in order to support the recovery and build back a stronger and more resilient NHS. The College will work with senior stakeholders to promote the application of these lessons across the healthcare sector.  

The risk of new COVID-19 variants coinciding with annual winter pressures and recurring peaks of infection from flu and respiratory diseases threatens to overwhelm healthcare services.  If critical care is once again pushed beyond capacity, this will jeopardise the NHS recovery. Our report outlines how the NHS must be better prepared for potential additional COVID-19 surges, with consideration of supply of PPE, pandemic skills maintenance, and the need for staff to be protected from burnout and given the opportunity to recover. The report also highlights the importance of innovation and new ways of delivering care, including the expansion of perioperative and enhanced care to optimise surgical activity.

Over the next few years, the biggest challenge for the healthcare service will be to tackle the backlog in planned surgery built up prior to and during the pandemic. With data from the College census1 showing at least one consultant vacancy in 90 per cent of all anaesthetic departments, we argue that any recovery plans must be underpinned by an investment in staff and long-term workforce planning.

The RCoA’s 10 lessons learnt from the pandemic:

  1. the wellbeing of NHS staff is paramount
  2. staff shortages must not persist, now is the time to invest in workforce
  3. we need increased critical care capacity across the UK
  4. appropriate and timely supply of PPE is key
  5. perioperative care has a critical role to play in the NHS recovery and beyond
  6. we should maintain pandemic skills
  7. collaboration and information sharing are critical for a successful pandemic response
  8. local decision-making works
  9. the healthcare system must be better prepared for future pandemics
  10. there is huge potential for digital innovations

Professor Ravi Mahajan, President of the Royal College of Anaesthetists said:

“Anaesthetists, alongside other healthcare professionals, have adapted incredibly well during the pandemic to look after the sickest COVID-19 patients. Over half2 of our members said they had acquired new, transferrable skills, and it is now crucial that staff are supported to maintain the knowledge gained so we can build a pool of ‘reservists’ who can quickly step up to support ICUs when needed.

“Alongside the positive lessons, the pandemic has shone a light on the underinvestment in critical care services which has contributed to the suspension of elective activity and a significant increase in waiting lists. While investment in facilities such as protected elective surgical units are part of the solution, without the workforce capacity to staff them we will never be able to make full use of any additional resources.

“Now is the time to invest in increasing training places for anaesthetists, surgeons, nurses, and others as they look towards tackling the extensive backlog. It is also vital that the NHS appreciates and retains the staff currently working in the system and provides them with the best physical and psychological support as they begin their journey to build back the NHS.

“The fortitude, dedication and adaptability of the NHS staff during the pandemic has demonstrated what they and the NHS are capable of when under pressure. There must be a commitment from the UK government to continue the move towards a more innovative and solutions-focused healthcare system. The NHS must not be left to return to business as usual. The government and the NHS must grab this opportunity to embed what has been learnt so far and continue to learn and improve so we can build a truly sustainable health service.”

Dawn Chamberlain, Director of Clinical Improvement, NHS England and NHS Improvement said:

“The way that the NHS has adapted in response to the pandemic has been phenomenal. We have seen changes to the way we work within our teams, across organisational boundaries and how we interact with our patients, carers and citizens. We must learn lessons from the pandemic to ensure that future generations benefit from these changes. I welcome the learning from the Royal College of Anaesthetists report to support the recovery of the NHS.”


  1. RCoA Medical Workforce Census Report 2020
  2. COVID-19 Winter Survey. February 2021

PDF of the report:  Royal College of Anaesthetists – 10 lessons learnt from COVID-19.pdf

Link to the report: 10 lessons learnt from COVID-19

Royal College of Anaesthetists’ President Writes to Secretary of State on Behalf of Anaesthetists in Training

May 21, 2021

The Royal College of Anaesthetists is continuing to work closely with the Department of Health and Social Care, Health Education England and other devolved nation stakeholders to negotiate a solution to ST3 recruitment.

The Royal College of Anaesthetists

College President, Professor Ravi Mahajan, has written to the Secretary of State for Health and Social Care, suggesting the following short-and-long term solutions:

  • to divert some of the additional funding allocated to tackling the surgical backlog to create additional Trust grade posts for anaesthetists in training who have been unsuccessful in this year’s recruitment round, so that they can continue to provide much needed anaesthetic cover for surgical procedures
  • to ensure that any workforce experience that anaesthetists in training gain outside of recognised training programmes is appropriately recognised as part of their anaesthetic training. The College is writing to all deaneries and Heads of Schools to ensure that they follow our equivalent training guidance
  • to consider an essential increase in anaesthetic training numbers in light of the fact that, even after the end of this year’s recruitment round, it is likely that a considerable number of anaesthetists in training will have been unsuccessful in securing a place. The current situation offers an excellent opportunity for a one-off increase in Higher Specialty Training recruitment that would provide significant mitigation for the current and future shortfall in consultant numbers after just four years rather than the usual seven-year programme.

Professor Ravi Mahajan, President of the Royal College of Anaesthetists said:

“Anaesthetists in training have worked tirelessly to support the response to the COVID-19 pandemic and in doing so, many have experienced significant disruption to their training. This has been compounded by the disappointing situation where many will have been unsuccessful in their recent applications for higher training posts. I was therefore pleased to see the announcement from Health Education and Improvement Wales that an increase in the number of anaesthetic training posts in that nation is being delivered for August 2021. I hope to see similar decisions being made across the devolved nations and I look forward to working with the Department of Health, Health Education England and the other Statutory Education Bodies to help make this happen.”

As negotiations continue, the College will provide updates to its anaesthetists in training and wider membership, where substantial progress is made.

If anaesthetists in training have further questions about their recruitment, or the introduction of the 2021 Anaesthetics Curriculum, please speak with your College Tutor, Regional Advisor Anaesthesia or Training Programme Director.

Alternatively, the College Training Team can be reached at, or the Chair and Deputy Chair of the Anaesthetists in Training Committee can be reached via

Ysbyty Gwynedd Becomes First Hospital in Wales to Receive Prestigious Royal College of Anaesthetists Award

April 7, 2021

The Anaesthetic department at Ysbyty Gwynedd in Bangor has been recognised for providing the highest quality of care to their patients.

Royal College of Anaesthetists (RCoA)

The hospital has become the first in Wales to be awarded the prestigious Anaesthesia Clinical Services Accreditation (ACSA) from the Royal College of Anaesthetists (RCoA).

The ACSA accreditation is the RCoA’s peer-reviewed scheme that promotes quality improvement and the highest professional standards of anaesthetic service. To receive accreditation, anaesthetic departments are expected to demonstrate high standards in areas such as patient experience, patient safety and clinical leadership.

The Anaesthetic teamwork across the hospital and provide anaesthesia services for all types of surgery, labour delivery suites, pre-operative assessments, pain services and are in charge of the Intensive Care Unit that looks after the most critically unwell patients in the hospital.

Dr Tony Shambrook, Consultant Anaesthetist and ACSA Lead at Ysbyty Gwynedd, said:

“We are extremely proud and honoured to be the first hospital in Wales to receive ACSA accreditation.

“It has been a long process over two years to meet all 145 standards to achieve this award. A great deal of work has gone on behind the scenes, from investing in new equipment to updating policies and guidelines to ensure we achieved it.

“Our main focus is putting our patients first and ensuring patient safety is at the heart of everything we do. The ACSA process has helped to highlight how we can improve as a department to ensure we are delivering safer patient care and better patient experience.

“I would like to say a special thank you to my colleagues Dr Ian Johnson, Dr Jason Walker and Dr Linda Warnock for their assistance with coordinating this project.”

Dr Abrie Theron, Chair of the Welsh Board, Royal College of Anaesthetists, said:

“I would like to offer my personal congratulations to the entire anaesthetic team at Ysbyty Gwynedd in Bangor for their ACSA accreditation. Receiving this award is a significant achievement, and I am delighted that we have our first Welsh department accredited under the scheme. It is richly deserved and demonstrates their commitment to providing the best possible care for their patients.

“Patient safety is at the heart of what we do as a Medical Royal College. The quality improvement demonstrated during the accreditation process has helped the department manage the immense tasks presented to them by COVID-19 and the resumption of normal services.  

“Ysbyty Gwynedd has worked hard to keep patients as the primary focus and deliver excellent flexibility to match patient’s needs. Many innovative practices are taking place at this hospital.

“As well as meeting the standards, the department demonstrated many areas of excellent advanced practice that have now been highlighted for sharing through the ACSA network.”

Dr Karen Mottart, Consultant Anaesthetist and Ysbyty Gwynedd Medical Director said:

“Achieving this accreditation is a testament to the hard work of the Anaesthetic Department here at Ysbyty Gwynedd.

“This is a huge achievement in a time of challenge and evidence that a District General Hospital can deliver high quality patient care.  

“We are very proud to be the first hospital in Wales to achieve this award and we will continue to work with the RCoA to maintain these standards.”

Login to your account