Views on Healthcare Quality: WHO ‘Safe Surgery Saves Lives’ Checklist: NABH COP 14

Saturday, 21 July 2012

WHO ‘Safe Surgery Saves Lives’ Checklist: NABH COP 14

While dealing with care of patients who are undergoing surgical procedures, NABH recommends hospitals to refer to WHO ‘Safe Surgery Saves Lives’ Initiative. In this post, I bring to you a complete detail around the initiative and the checklist. This is also an important example that Dr. Atul Gawande quotes in his book – ‘The Checklist Manifesto: How to get things right’ and is one of my favourite books.

All the references are from the WHO’s website.

You can read an overview of the checklist on this page:

You can have a look at this 19 pointer checklist on the 20th page of the pdf available on this link:

I am sure you will have a lot of questions on what this checklist is all about and how to use it and is it applicable in your hospital. Don’t worry, WHO provides answers here:

And if you want to get a feel of how to do this checklist, watch the video below:

I’ve shown this video to 2 different audiences and both agreed that this checklist is short and crisp and can take care of a lot of elementary goof-ups that happen in their OTs and enhance patient safety. If you noticed, it doesn’t take more than 2 minutes each time you do the checklist. I think that’s time worth spent in protecting our patients.

Update on 30/08/2013
Based on a viewer comment, I felt there have to be other illustrations and videos for Safe Surgery Checklist which helps in better understanding of its implementation.

Below is a video from a hospital in Australia where a patient is undergoing Hip Replacement procedure. This one has the Pre-Incision (Time-Out) and Post-Procedure (Sign-Out) shoot only, but in a better detail.

This is another video from St. John of God Hospital in Australia. This one has two-part, the first one about how to do the Safe Surgery Checklist, and the second one about how not to do the checklist.


  1. this is one of the beautiful time out process to ensure patient safety. my concerns here are
    1. in sign all the surgical team should be present. in the video it was not happened. the site verification also must be done or addressed before draping.
    the antibiotic prophylaxis should come before time out or at least in sign in process time. if at all a forgotten antibiotics can be administered that time, not just before incision, to have the maximum effective concentration of antibiotics in blood level
    2. the equipment verification is confirmed in the timeout process. if it is not working or the surgeon is saying additional instruments, patients is under anaesthesia. who will arrange it. what is the time delay....cannot agree with it.
    3. the sign out should happen after the wound closure only. the final count of all the swabs and instruments can be declared only after the final closure, not at all before that

    1. Thanks Jeril for sharing your concerns and I am happy that this helps clarifying issues about implementation of WHO-SSC. I have checked online for better videos, however, my effort has been in vain. But I will make a collection of videos in this post where various aspects of SSC are discussed in specific detail. Now coming to the response to your concerns:
      1. In this video, the nurse observes that the surgical site is not marked because it's not applicable.
      You made a good observation about antibiotic prophylaxis being talked in the Time-Out and not in Sign-In. Well, there's a mention in Dr. Atul Gawande's book (if I'm recollecting it correctly) that WHO conducted a global study to find out potential errors that happen in surgeries world-wide and one of the observation was about antibiotic administration. Now, the fact that antibiotic prophylaxis is asked just before incision is to stop the procedure if prophylaxis's not been given. This checklist has a specific objective to catch errors and stop the surgeries from proceeding. So yes, it makes sense to check about antibiotic prophylaxis pre-incision.
      2. Again, your point is relevant but you are seeing it from the point-of-view of ensuring that the surgery happens. That's where the faults have been happening, where we just want to get the whole procedure through without wasting time. The fact remains that many things go unchecked or are reported incorrectly before the patient is brought to the OT/OR. That's why the checklist demands that just before incision, FOR THAT ONE LAST TIME, please check if everything is in place!
      3. I believe the purpose of the Sign-Out is to make checks before taking the patient out of the OT/OR. Therefore, wound closure would have happened by the time you do Sign-out. I guess your concerns are all taken care of.

      I have found another video from South Australia which deals with a Hip Replacement procedure. Please check that video above.

  2. Thankyou very much for your feed back Mr. Anuj. My concerns about antibiotic prophylaxis is still with sign in time. the patient is under anaesthesia. Antibiotic forgot to given. The surgical team should wait another minimum 20 minutes for the incision. because antibiotic requires minimum 20 minutes to have the maximum effective concentration in the blood level. So a forgotten antibiotic will prolong the incision time, which can be avoided if it was done in Sign in time.
    in the second video, the patient is identified after induction of anaesthesia. since anaesthesia is also a different procedure, identification of the patient must be done before that. whereas in the first video the patient itself is a member of the team, which is well appreciated. i think a combination of all these videos will give a better practice
    Jeril Cherian

    1. Yeah, I think your observations are bang-on-target and I am happy to have this discussion here because it will help a lot of professionals in this country who are serious about healthcare quality. You are right that none of the videos do complete justice to the concept of Safe Surgery Checklist. Unfortunately I haven't been able to trace a satisfactory illustration of the SSC.

  3. well, i have seen the third video, the second part is the real one, which happens everywhere; the surgeons's (majority) as usual shows their ego again.
    in fact in the correct technique, it is not about the procedure. under no circumstances patient chest, abdomen or any part of the body is not a place to keep the file. they should have avoided that. on the other hand the anaesthesiologist wearing gloves is handling the file. after wearing the gloves, whether it is used or not used you cannot handle the file with a gloved hand
    jeril cherian

    1. These are very pertinent objections and yes, it defeats the purpose of the SSC itself if people were to touch the file with their gloves on!
      May I request you to contribute to this blog by the way of 'Key points to remember/avoid' while planning/conducting a surgery, which will be an additional set of advice on top of Safe Surgery Checklist.