Original article

Compliance and use of the World Health Organization checklist

in UK operating theatres
S. P. Pickering1 , E. R. Robertson2 , D. Griffin1 , M. Hadi1 , L. J. Morgan2 , K. C. Catchpole5 , S. New3 ,
G. Collins4 and P. McCulloch2
1
Warwick Orthopaedics, Warwick Medical School, University of Warwick, Coventry, and 2 Quality, Reliability, Safety and Teamwork Unit, Nuffield
Department of Surgical Sciences, 3 Saı̈d Business School and 4 Centre for Statistics in Medicine, University of Oxford, Oxford, UK, and 5 Department of
Surgery, Cedars-Sinai Medical Center, Los Angeles, California, USA
Correspondence to: Mr P. McCulloch, Quality, Reliability, Safety and Teamwork Unit, Nuffield Department of Surgical Sciences, University of Oxford,
Oxford OX3 9DU, UK (e-mail: peter.mcculloch@nds.ox.ac.uk)

Background: The World Health Organization (WHO) Surgical Safety Checklist is reported to reduce
surgical morbidity and mortality, and is mandatory in the UK National Health Service. Hospital audit data
show high compliance rates, but direct observation suggests that actual performance may be suboptimal.
Methods: For each observed operation, WHO time-out and sign-out attempts were recorded, and the
quality of the time-out was evaluated using three measures: all information points communicated, all
personnel present and active participation.
Results: Observation of WHO checklist performance was conducted for 294 operations, in five hospitals
and four surgical specialties. Time-out was attempted in 257 operations (87·4 per cent) and sign-out in 26
(8·8 per cent). Within time-out, all information was communicated in 141 (54·9 per cent), the whole team
was present in 199 (77·4 per cent) and active participation was observed in 187 (72·8 per cent) operations.
Surgical specialty did not affect time-out or sign-out attempt frequency (P = 0·453). Time-out attempt
frequency (range 42–100 per cent) as well as all information communicated (15–83 per cent), all team
present (35–90 per cent) and active participation (15–93 per cent) varied between hospitals (P < 0·001
for all).
Conclusion: Meaningful compliance with the WHO Surgical Safety Checklist is much lower than
indicated by administrative data. Sign-out compliance is generally poor, suggesting incompatibility with
normal theatre work practices. There is variation between hospitals, but consistency across studied
specialties, suggesting a need to address organizational culture issues.

Paper accepted 22 August 2013

Published online in Wiley Online Library (www.bjs.co.uk). DOI: 10.1002/bjs.9305

Introduction
The World Health Organization (WHO) launched the
Safe Surgery Saves Life campaign1 in January 2007, to
improve consistency in surgical care and adherence to
safety practices. In June 2008, the WHO Surgical Safety
Checklist was designed to help operating room staff
improve teamwork and ensure the consistent use of safety
processes2 . The WHO checklist has become one of the
most significant and widely used innovations in surgical
safety of the past 20 years1,3,4 .
Large benefits have been reported following implemen-
tation of the checklist, including reductions in adverse
events3 and cost savings5 . Based on these reports, the
WHO Surgical Safety Checklist has been regarded as
highly successful. Claims have been made for its capacity
to induce indirect changes, such as improved situational
awareness, in line with the evidence that structured
briefings and checklists improve factors such as team
communication and information sharing6 .
The WHO Surgical Safety Checklist has since been
taken up by national healthcare governance organizations
in the USA and UK to ensure target compliance. In
the UK National Health Service (NHS), hospitals are
required to audit and report their adherence rates to meet
set targets, and compliance is encouraged by a financial
incentive. However, clinical audit studies of WHO
Surgical Safety Checklist compliance have questioned
the quality of compliance with the time-out and sign-out
sections of the checklist7 .

 2013 British Journal of Surgery Society Ltd British Journal of Surgery 2013; 100: 1664–1670
Published by John Wiley & Sons Ltd
Use of the World Health Organization checklist in UK operating theatres 1665

Audits of WHO Surgical Safety Checklist compliance
to fulfil regulatory requirements intend to record whether
all sections of the checklist are performed. These audits
commonly record only the fact that an attempt was made,
not whether the attempt was adequate to fulfil its intended
purposes. Reports of problems with implementation and
application8 of the WHO Surgical Safety Checklist in the
operating room have suggested that achieving compliance
to a level where benefit can reasonably be expected is more
complex than expected9 .
There is little or no objective evidence as to how
widespread such problems of compliance might be,
although the effectiveness of the checklist as a safety tool
is likely to be affected by poor implementation.
Five years after global implementation, the purpose
of this study was to explore how the WHO Surgical
Safety Checklist is being used in practice in the UK. The
objectives of the study were to assess WHO Surgical Safety
Checklist performance quality by observing the time-
out and sign-out sections during emergency and elective
surgical procedures.
Methods
The data for this study were collected as part of a
multicentre observational and quality improvement study,
the Safer Delivery of Surgical Services, at three NHS
Trusts with a total of five hospitals: one district general
hospital, three teaching hospitals and one tertiary referral
centre. A variety of surgical procedures were directly
observed in their entirety by a pair of observers, one with a
background in surgery and the other in human factors (HF)
science. Observations were made in elective orthopaedic,
trauma orthopaedic, plastic, vascular and general surgery.
Within each surgical specialty a range of common surgical
interventions were selected for inclusion in the study
based on retrospective review of activity, and operating
lists were targeted with the highest proportion of the
predetermined case mix. On days when data collection
was scheduled, whole operating lists were observed,
meaning the operations were consecutive. The surgical
procedures that were observed constituted approximately
15–25 per cent of the operations for the teams within that
time interval and were therefore a large, representative
sample of contemporary activity within that theatre. The
case mix for each of the surgical specialties was as follows:
elective orthopaedics – primary and revision hip and
knee arthroplasties and arthroscopic procedures; trauma
orthopaedics – manipulation of fractures and dislocations
under anaesthesia, open reduction and either internal
fixations or hemiarthroplasty procedures; vascular and
general – arterial bypass, endarterectomies and hernia
repair; plastic surgery – excision of benign and malignant
lesions with a range of closure techniques including free
flaps, upper limb and nerve surgery.
Data collection protocols for each surgical procedure
were developed10 to record observational data, and a
dedicated section was created to record observations for
the WHO Surgical Safety Checklist time-out and sign-out
process based on the work of Lingard and colleagues11 .
Observers were trained in the use of these pro formas.
For reasons of limited space and patient comfort, the sign-
in section, which is performed in the UK in the small
adjoining anaesthetic room, was not observed.
The clinical observers included two surgical trainees
(M.H. and E.R.R.), one nurse practitioner (J.M.) and
three HF specialists (L.J.M., S.P.P. and L.B.) with higher
degrees in HF and/or psychology. Data collection was
completed in pairs, one HF specialist and one clinical
observer. A 2-month training phase was completed before

Table 1 Proportion of operations with attempts at World Health Organization time-out and sign-out in 294 operations at five hospital
sites

Site A Site B Site C Site D Site E Total for specialty

Time-out attempted
Elective orthopaedics 92 of 101 (91·1) 11 of 26 (42) 53 of 54 (98) 27 of 30 (90) – 183 of 211 (86·7)
Trauma orthopaedics – – 16 of 16 (100) – – 16 of 16 (100)
Vascular surgery – 15 of 21 (71) – – 24 of 24 (100) 39 of 45 (87)
Plastic surgery 19 of 22 (86) – – – – 19 of 22 (86)
Total per site 111 of 123 (90·2) 26 of 47 (55) 69 of 70 (99) 27 of 30 (90) 24 of 24 (100) 257 of 294 (87·4)
Sign-out attempted
Elective orthopaedics 4 of 101 (4·0) 2 of 26 (8) 3 of 54 (6) 0 of 30 (0) – 9 of 211 (4·3)
Trauma orthopaedics – – 0 of 16 (0) – – 0 of 16 (0)
Vascular surgery – 0 of 21 (0) – – 17 of 24 (71) 17 of 45 (38)
Plastic surgery 0 of 22 (0) – – – – 0 of 22 (0)
Total per site 4 of 123 (3·3) 2 of 47 (4) 3 of 70 (4) 0 of 30 (0) 17 of 24 (71) 26 of 294 (8·8)

Values in parentheses are percentages.

 2013 British Journal of Surgery Society Ltd www.bjs.co.uk British Journal of Surgery 2013; 100: 1664–1670
Published by John Wiley & Sons Ltd
1666 S. P. Pickering, E. R. Robertson, D. Griffin, M. Hadi, L. J. Morgan, K. C. Catchpole et al.

All information communicated

n = 141 (54·9%)

Time-out performed All team present

n = 257 (87·4%) n = 199 (77·4%)

Time-out not performed Active participation

n = 37 (12·6%) n = 187 (72·8%)

No. of operations n = 294

All information communicated

n = 20 (77%)

Sign-out performed All team present

n = 26 (8·8%) n = 18 (69%)

Sign-out not performed Active participation

n = 268 (91·2%) n = 20 (77%)

Fig. 1 Quality of the time-out and sign-out process at all National Health Service sites

observations were commenced, in which the HF specialists
were introduced to the operating theatre and the surgical
operations, and the clinical observers received lecture-
based training on the principles of HF.
Intraoperative observation began when the patient
entered the operating theatre and ended when they left
it. Observers recorded whether a time-out or sign-out was
attempted and, if it was, the attempted process was critiqued
on three quality parameters: whether all information
was communicated, whether all team members were
present, and whether active participation was noted. These
parameters each received a yes/no result individually. ‘All
team present’ required all of the team members taking
part in the operation to be present at its commencement;
‘all information communicated’ required all points on the
checklist to be addressed verbally; and ‘active participation’
required whole-team interaction and engagement with
checklist completion. Observers recorded these parameters
independently for the time-out and sign-out, including the
onset time and duration of the process. The person leading
the time-out and sign-out was also recorded, defined as
the team member who read aloud the checklist questions
to the rest of the team. Following the conclusion of each
operation, observers compared findings and resolved any
disagreement by discussion.
Observation of the WHO time-out and sign-out was
performed within the context of a wider study of work,
the Safer Delivery of Surgical Services (S3), which aims to
quantify the effect of quality improvement interventions
on theatre processes and safety. The observation of the
WHO time-out and sign-out was selected as an outcome
measure for the S3 study. In this paper all preintervention
assessment data are presented.
All theatre staff included in the study were consented
for participation under ethical clearance from the Oxford
A Ethics Committee (REC:09/H0604/39).
Statistical analysis
The study was exploratory and therefore largely descriptive
statistically. Continuous data are summarized by the
median, interquartile range (i.q.r.) and range. Binary
data are summarized as proportions. Comparison of
proportions was performed with the χ2 test; P < 0·050 was
considered statistically significant. All statistical analyses
were performed in R version 2·15·3 (http://www.r-
project.org/).
Results
A total of 294 operations were observed across five NHS
sites, between January 2011 and September 2012 (elective
orthopaedics, 211 operations; trauma orthopaedics, 16;
vascular surgery, 45; plastic surgery, 22). A greater number
of observations were completed in orthopaedics as this was
the main surgical specialty under study.
Completion of World Health Organization
time-out and sign-out
Of the 294 observed operations, time-out was attempted in
257 and sign-out in 26. There was no significant difference

 2013 British Journal of Surgery Society Ltd www.bjs.co.uk British Journal of Surgery 2013; 100: 1664–1670
Published by John Wiley & Sons Ltd
Use of the World Health Organization checklist in UK operating theatres 1667

100

75
Completion (%)

50

25

0
Site A orthopaedics Site A plastics Site B orthopaedics Site B vascular Site C orthopaedics Site C trauma Site D orthopaedics Site E vascular Total
n = 101 n = 22 n = 26 n = 21 n = 54 n = 16 n = 30 n = 24 n = 294

a Time-out

100
All information communicated
All team present
Active participation
75
WHO time-out/sign-out attempted
Completion (%)

50

25

0
Site A orthopaedics Site A plastics Site B orthopaedics Site B vascular Site C orthopaedics Site C trauma Site D orthopaedics Site E vascular Total
n = 101 n = 22 n = 26 n = 21 n = 54 n = 16 n = 30 n = 24 n = 294

b Sign-out

Fig. 2 Attempt frequency and quality of the World Health Organization (WHO) time-out and sign-out process

Table 2Time-out quality parameter results and associated Table 3 Quality of time-out by specialty of time-out lead
proportion with sign-out attempted
Anaesthesia Surgical Nursing
Time-out Sign-out (n = 40) (n = 59) (n = 149) P*
compliance compliance
All information communicated 19 (48) 34 (58) 84 (56·4) 0·554
(n = 294) (n = 26)
All team present 36 (90) 46 (78) 114 (76·5) 0·172
All parameters 99 (33·7) 19 of 99 (19) Active participation 33 (83) 38 (64) 112 (75·2) 0·111
Two of three parameters 88 (29·9) 6 of 88 (7)
Values in parentheses are percentages. *χ2 test.
One of three parameters 54 (18·4) 1 of 54 (2)
No parameter 16 (5·4) 0 of 16 (0)
WHO time-out not attempted 37 (12·6) 0 of 37 (0) the accompanying paper checklist was destroyed at the end
Values in parentheses are percentages. WHO, World Health of the operation.
Organization.

in the attempt rate of time-out and sign-out between Performance time for time-out and sign-out
surgical specialties (P = 0·453). However, a significant process
difference in the proportion attempting a time-out was The median time taken to perform a time-out was 60 (i.q.r.
observed between hospital sites (P < 0·001) (Table 1). 55–80, range 10–240) s, and that for a sign-out was 60
In one of the sites (site A), signatures to mark completion (i.q.r. 50–60, range 30–180) s.
of the checklist were done electronically; in all other
sites signatures were marked on the paper version of
Quality of the World Health Organization
the checklist. At sites where completion of the checklists
time-out and sign-out
was paper-based, these were archived after completion of
the operation in the patient’s notes. At the site where Assessment of the quality of the time-out and sign-out is
checklist use was confirmed with an electronic signature, represented in Fig. 1.

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Published by John Wiley & Sons Ltd
1668 S. P. Pickering, E. R. Robertson, D. Griffin, M. Hadi, L. J. Morgan, K. C. Catchpole et al.
For time-out, the quality criterion complied with least
commonly was ‘all information communicated’, with only
slightly more than half of theatre teams communicating
the full checklist. Compliance with the other two criteria,
‘all team present’ and ‘active communication’, was over 70
per cent. Combining these three parameters and assessing
them against the time-outs attempted can give an indication
of the quality of the time-out process, which showed a
significant difference between hospital sites (P < 0·001).
The sites and specialties differed in their method of
completion (Fig. 2). For example, active communication
in time-out was particularly low for site D orthopaedics,
indicating that the WHO checklist was often completed
by one person who did not verbalize the content to the rest
of the team.
Association between time-out and sign-out
completion
For the 26 operations where a sign-out was attempted,
a time-out had been performed previously. There were
no occasions where a sign-out was performed without a
pre-existing time-out.
Owing to the paucity of occasions where the WHO
sign-out was attempted, further quality analysis was not
performed in detail. Table 2 shows the details of WHO
time-out performance with one, two or all three quality
parameters. Of the time-outs attempted, a small propor-
tion, 16 (5·4 per cent) of 294 operations, did not score for
any of the quality parameters. When only one parameter
was observed, it was most frequently that all team members
were present (34 of 257, 13·2 per cent). When two para-
meters were observed present, ‘all information communi-
cated’ was most likely to be missing (58 of 257, 22·6 per
cent).
Impact of leader on quality of the World Health
Organization time-out
The quality of the WHO time-out process was not
affected significantly by the discipline of the operating
team member (anaesthetic, surgical or nursing) who led
the time-out (Table 3).
Discussion
In this direct observation study, the time-out section of the
WHO Surgical Safety Checklist was usually attempted,
but the sign-out section was not. A difference in adherence
was found between NHS sites, but not between surgical
specialties, and the identity of the time-out process
leader made no difference to compliance. Three simple
measures were used to assess how well the time-out
 2013 British Journal of Surgery Society Ltd
Published by John Wiley & Sons Ltd
was performed, and satisfactory performance on all three
measures occurred in only 38·5 per cent of observed
operations (99 of 257). These findings are in stark contrast
to administrative audits reporting compliance rates of
between 66 and 100 per cent9 . Interestingly, administrative
audits were completed at each of the sites while this study
was ongoing, and all showed high levels of compliance
(more than 95 per cent).
The data are of concern because the benefits claimed
for the checklist3 are contingent on it being performed
reliably14 , and it is reasonable to assume that poorly
performed time-out and unperformed sign-out procedures
will detract significantly from the effectiveness of the
checklist in reducing patient harm. Indeed, poorly used
checklists may have detrimental effects on safety and
teamwork both in aviation12 and in the operating
theatre. ‘Widespread deployment of checklists without an
appreciation of how or why they work is a potential threat
to patients’ safety and to high-quality care’8 .
The performance deficits found in this study display
characteristics more in keeping with violations, defined
as ‘behaviours that involve deliberate deviations from the
written rules’13 , than with other categories of process
deviation. Checklists have been used to improve safety
for decades in many high-risk industries, with apparent
success14 , but questions have arisen about their ease of
introduction into workflow patterns and their true impact
on safety15,16 . Potential barriers include cultural accep-
tance, poor training and faulty implementation strategy8 .
Violations may result from disengagement with the
process, when checklists can become ‘tick-box’ exercises.
The design of the checklist itself must also be addressed
as a potential source of adherence problems. It seems
clear from the low implementation rate of the sign-out
procedure across different locations and specialties that
this part of the checklist has some serious incompatibilities
with standard operating theatre practice and culture
in the UK. Sign-out is supposed to be performed at a
time of particularly high workload for theatre nursing
and anaesthetic staff. Observational impressions and
discussions with theatre staff reinforce the argument
from ergonomic principles that, as currently performed,
sign-out represents an additional source of stress and
workload to be managed concurrently with competing
demands. Checklists can be vital at times of high workload,
but only if they are used as the framework for performing
the activities required14 ; if not used in this way they may
represent a risk, in the form of an additional demand on
already divided attention17 . Sign-out therefore needs to be
redesigned so that it is better integrated with the realities
of workload in busy operating theatres.
www.bjs.co.uk British Journal of Surgery 2013; 100: 1664–1670
Use of the World Health Organization checklist in UK operating theatres
Checklists appear in many different forms and the
philosophy of checklists is well established18 . The WHO
Surgical Safety Checklist is designed to be generic and
adaptable, but the manner of implementing it in many UK
Trusts discouraged or forbade modification19 , leaving staff
in many hospitals frustrated and disengaged by obvious
mismatches between the process they were mandated to
follow and their specific local needs. Another important
aspect of implementation strategy that may have had
unintended consequences was mandatory reporting of
compliance by hospitals, with a 100 per cent target.
This may potentially have encouraged tick-box compliance
without engagement by staff with the meaning and purpose
of the activity20 . Political and public awareness of patient
safety issues is increasing pressure for compliance rates to
be visible in the public domain, and these are now appearing
on Trust websites21 – 24 . This development carries a risk that
WHO Surgical Safety Checklist compliance could become
more important as an advertising tool than as part of a
strategy for risk reduction.
The finding that interhospital differences were signifi-
cant, whereas interspecialty differences were not, suggests
that these differences were a result of organizational cul-
ture at the local (theatre suite or Trust) level. However,
these findings must be regarded as suggestive rather than
conclusive, because the number of hospitals and specialties
compared was small. At one site, WHO checklist compli-
ance appeared particularly low. Real compliance did not
seem to be affected by the person who led the time-out.
This work extends and confirms similar findings from
smaller studies. One investigation9 found that items
were confirmed more commonly during time-out (range
100–72 per cent) than during sign-out (range 86–19 per
cent), but only 13 per cent of time-outs and 3 per cent
of sign-outs were checked properly (all items validated).
Sivathasan and co-workers25 asked 421 hospitals in the UK,
before the national roll-out, about use of the surgical safety
checklist and found that it was compulsory in 65 per cent.
They argued that much greater education and awareness
would be needed for the roll-out to be effective. Rydenfält
et al.26 reported in a study of 24 videoed operations that
‘The checklist is not always applied as intended. The com-
ponents that facilitate communication are often neglected.
The time-out does not appear to be conducted as a team
effort . . . To improve compliance and involve the whole
team, the concept of risk and the perceived relevance of
checklist items for all team members should be addressed’.
The strengths of this study included the large sample
size, the direct observation methodology, the use of paired
observers combining clinical and HF expertise, and the
use of several hospital settings. The assessment tool for
 2013 British Journal of Surgery Society Ltd
Published by John Wiley & Sons Ltd
1669
time-out quality appears to be sensitive and easy to use.
Limitations include the risk of a Hawthorne effect (imply-
ing that normal adherence might have been even worse),
the relatively limited spread of hospitals and specialties
involved, and a degree of subjectivity in deciding whether
all staff were actively engaged. The hospitals involved
represented a balanced mix of types (university, specialist
and district general), but are a small sample of the whole
hospital sector; a different sample might therefore yield dif-
ferent results. However, the core findings around time-out
and sign-out quality overall seem robust. The data collec-
tion approach resulted in interobserver reliability not being
evaluable, which would have added strength to the method.
The WHO Surgical Safety Checklist is not being
used appropriately in typical NHS Trusts. The sign-out
procedure is used particularly poorly, suggesting a basic
incompatibility with the work systems of NHS operating
theatres. The patient safety benefits intended by the
WHO Surgical Safety Checklist are unlikely to be realized
unless real compliance is improved considerably.
Acknowledgements
The authors thank the management, surgical, anaesthetic
and theatre staff at the Trusts and sites that took part in
this study for their cooperation and forbearance: Oxford
University Hospitals Trust (Nuffield Orthopaedic Cen-
tre), Coventry and Warwick University Hospitals Trust
(Hospital of St Cross, Rugby, and University Hospital,
Coventry), and Kettering District General Hospital Trust.
The authors also thank J. Matthews and L. Bleakley for
assistance in the intraoperative data collection.
This paper presents independent research funded by
the National Institute for Health Research (NIHR) under
its Programme Grants for Applied Research programme
(reference no. RP-PG-0108-10020). The views expressed
are those of the author(s) and not necessarily those of the
NHS, NIHR or the Department of Health.
Disclosure: The authors declare no conflict of interest.
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