What is an apparent effect of the surgical safety checklist, which includes sign in, time out, and sign out protocols, as recommended by the World Health Organization (WHO) guidelines for safe surgery?

Effect of the WHO Surgical Safety Checklist on Patient Outcomes

The WHO Surgical Safety Checklist significantly reduces postoperative complications and mortality rates in both high and low-income settings, with higher rates of antibiotic administration within 60 minutes of operation being one of its most apparent effects. 1

Overview of the WHO Surgical Safety Checklist

The World Health Organization (WHO) published the Surgical Safety Checklist (SSC) in 2008 to improve patient safety during surgery. This 19-item checklist includes three critical pause points (sign in, time out, and sign out) that surgical teams use to confirm appropriate actions are taken throughout the perioperative period and ensure shared understanding among team members. 1

Key Effects of the Surgical Safety Checklist

Improved Antibiotic Administration Timing

• Implementation of the checklist has been associated with higher rates of antibiotic administration within 60 minutes of operation, which is critical for preventing surgical site infections 1
• The checklist specifically includes verification of antibiotic prophylaxis administration within 1 hour of incision to obtain the highest drug serum levels at the time of incision 1

Reduced Mortality and Complications

• Meta-analyses show the use of the checklist is associated with:

  • Reduced mortality (odds ratio 0.75,95% CI 0.62-0.92) 2
  • Reduced overall complications (odds ratio 0.73,95% CI 0.61-0.88) 2
  • Reduced surgical site infections (risk ratio 0.57,95% CI 0.41-0.79) 3

• In the original WHO study across eight diverse hospitals worldwide, implementation of the checklist resulted in:

  • Reduction in death rates from 1.5% to 0.8% (P=0.003) 4
  • Reduction in inpatient complications from 11.0% to 7.0% (P<0.001) 4

Effectiveness in Urgent Surgical Cases

• The checklist has demonstrated effectiveness even in urgent surgical procedures (required within 24 hours):
  • Complication rates decreased from 18.4% to 11.7% (P=0.0001) 5
  • Mortality rates decreased from 3.7% to 1.4% (P=0.0067) 5
  • Adherence to measured safety steps improved from 18.6% to 50.7% (P<0.0001) 5

Benefits Across Different Healthcare Settings

• The checklist has shown significant benefits in both high-income and low-income settings 1, 4
• It is considered one of the most affordable and sustainable tools for reducing deaths from surgery in low-middle-income countries (LMICs) 1
• Despite evidence of effectiveness, acceptance and adoption of the SSC remain suboptimal (20-40%) in LMICs due to resource limitations and infrastructure challenges 1

Implementation Considerations

• The checklist should be implemented as part of a broader quality improvement initiative 1
• Successful implementation requires:
  • Multidisciplinary team involvement 1
  • Leadership support and commitment 1
  • Regular auditing and feedback on compliance 1
  • Integration with existing workflows to avoid overburdening clinicians 1

Common Pitfalls and How to Avoid Them

• Checklist fatigue: Avoid implementing too many checklists simultaneously, which can lead to reduced compliance 1
• Superficial implementation: Ensure the checklist is used meaningfully rather than as a "tick-box" exercise 1
• Lack of team engagement: Include all team members in the implementation process to increase buy-in 1
• Failure to adapt to local context: While maintaining core safety elements, consider adapting the checklist to local needs and resources 1

Based on the evidence presented, the most apparent effect of the WHO Surgical Safety Checklist is higher rates of antibiotic administration within 60 minutes of operation (option A), which is specifically emphasized in the checklist and has been consistently demonstrated in implementation studies.