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Patient Safety First case study

How implementing the surgical safety checklist improved staff teamwork in theatre

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With the help of Patient Safety First, Guy’s and St Thomas’ Foundation Trust has introduced the surgical safety checklist to reduce harm in perioperative care


Keywords Surgery, WHO surgical safety checklist, Patient safety

The surgical safety checklist from the World Health Organization (2009) improves communication and teamwork, while ensuring patients receive the safest care possible.Guy’s and St Thomas’ Foundation Trust has been working over the past year to implement the checklist as part of Patient Safety First’s reducing harm in perioperative care intervention.

The trust is a large organisation, employing around 10,000 staff and seeing around 850,000 patient contacts each year across two sites, so introducing the checklist was not an easy task.

Staff surveys show that communication has improved and checklists are being carried out reliably on a regular basis. Implementing the checklist means operating theatres are run by teams that communicate well, are efficient and effective and always put patient safety first.

Creating the patient safety working group

A specially created working group coordinated the checklist’s implementation, led by a consultant vascular surgeon. Along with clinical staff, anaesthetists and managers, the group had a large amount of nursing representation, with the deputy chief nurses and sisters from different theatres on board. Staff nurses were also invited to give feedback on areas relevant to them.

From the beginning, the working group emphasised the importance of engaging with frontline clinical staff who would be using the checklist in their day to day roles.

Implementing the checklist

The checklist was piloted at the St Thomas’ Hospital site before it was implemented across the whole trust in January 2010.

Implementation has not taken a one size fits all approach, and the working group has collaborated with staff to adapt the checklist to suit the needs of different specialties. For example, the question on anticipated blood loss had to be adapted for use in paediatric theatres as the wording was inappropriate for that patient group. Similarly, the checklist was adapted for dental operations as many of the questions would not apply to dental theatres.

A major consideration was that the checklist should not create any unnecessary paperwork for nursing staff. As a result, it was printed onto an A3 board in each theatre, and staff write on this instead of a separate piece of paper. We also adapted the perioperative care plan to include a colour coded section for recording completion of the checklist and to highlight any issues raised. Making the checklist more visual in this way has helped the team to focus communications and discuss plans for an operation more effectively.

Nurses’ role

To implement the checklist effectively, it was essential to engage all staff to ensure the theatre team worked together. Nursing staff have been involved at all stages of implementation and theatre sisters have been key in educating staff about the checklist’s advantages and in ensuring it is used for each patient. Nursing staff have reported that the “time out” stage of the checklist in particular has been enthusiastically received, part of which involves all team members introducing themselves by name and role. These introductions have created a more open environment where even junior staff members feel engaged and part of the team.


While the reaction from the majority of staff has been extremely positive, it was inevitable that not all would be immediately enthusiastic about such a comprehensive change. Members of the working group dealt with teething problems by:

  • Providing training sessions to staff;
  • Leading trust wide publicity campaigns;
  •  Working with individuals to identify any gaps or issues with implementation.

Without a doubt, the checklist works best when all staff members are engaged, so encouraging an open culture has been vital. Taking time to emphasise the ways in which the checklist can improve patient safety and theatre processes has been key.


At Guy’s and St Thomas’, we have benefited from the help and guidance available from the Patient Safety First website and useful events where we have had the opportunity to share and compare ideas with other trusts.

We have monitored the checklist’s implementation via a number of mechanisms including:

  • Observational audits of the checklist in use;
  • A notes review to ensure its use was being recorded appropriately in the patient record;
  • A staff survey to collect feedback on how effectively it is being used and to gather suggestions for improvement.

Communication and staff morale have definitely improved since the checklist was introduced.

Introducing the checklist has been a major work programme because of the trust’s size and complexity. However, it has been worth it and, so far, our audit results have shown it is being used as standard throughout theatres.

Implementation is not a static process; we will continue to monitor staff feedback and adapt the process wherever necessary.

AUTHORS Rachel Bell, MS, FRCS, is consultant vascular surgeon and clinical lead for the surgical safety checklist; Linnie Pontin, BA, is senior clinical governance manager; both at Guy’s and St Thomas’ Foundation Trust, London.


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