It was not uncommon for surgical patients to develop post-operative fever, infectious drainage from their incisions, sepsis and often death until the idea of sterile surgery came about in the late nineteenth century. Now improved anesthesia and infection prevention practices have allowed surgical advances such as open heart surgery and kidney transplants. But Surgical Site Infections (SSI) are still occurring though reducing risk is relatively simple and inexpensive when compared to the cost of the infections themselves, but in practice it requires commitment at all levels of the healthcare system.

Every operating room team can improve the safety and efficacy of care delivered to surgical patients. The World Health Organization (WHO) has created a starter kit that includes the Surgical Safety Checklist to help facilities identify gaps in their perioperative practice and then establish or confirm adherence to proven standards of care that can improve surgical results and decrease deaths and complications.

The Surgical Safety Checklist requires verification at three different stages of the procedure: before induction of anesthesia, before skin incision and before the patient leaves operating room.

How to Implement the Surgical Safety Checklist
The following points on implementing a surgical safety checklist in the OR are offered by the WHO. By following this checklist, facilities bring everyone closer to meeting the objectives of improved surgical care.

Build a team
Commitment by all clinical team members involved in surgical procedures is essential. Tell your colleagues about the checklist, starting with those who are likely to be most supportive. Include colleagues from all clinical disciplines (surgery, anesthesia, nursing) in these discussions. Identify a core group of people who are enthusiastic about the checklist while trying to involve at least one member from each of the clinical disciplines. At this early stage, work with those who are interested and willing to work with you, rather than trying to convince the most resistant people.

Meet with your organization’s leaders
Present the checklist to your organization’s leadership (see the PowerPoint presentation available at Emphasize the benefits of lower complication rates and the potential for cost savings. Support of this initiative by leaders in each of the clinical disciplines is critical to its success. Think about what the hospital leadership can do to promote the checklist.

Start small, then expand
With the help of organization leadership, run a campaign to get the checklist implemented in specific settings, for example a single operating room or within a single department. During the original evaluation by the WHO, sites that tried to implement the checklist in multiple operating rooms simultaneously or throughout the hospital faced the most resistance and had the most trouble convincing staff to use the checklist effectively. Start small, testing out the checklist in one operating room with one team and moving forward after problems have been addressed and when enthusiasm builds.

Use the checklist
Make sure your core team members are using the checklist in their own operating rooms. Slowly encourage others to adopt the checklist and work through potential concerns with them. Do not hesitate to customize the checklist for your setting as necessary, but do not remove safety steps just because you are having trouble accomplishing them.

Track changes
Collect data to see if the standards are being followed as the checklist is implemented in more operating rooms. Follow both process and outcome measures—for example, in what percent of operations are we giving antibiotics at the correct time? How many patients get surgical site infections?

Set public goals
Once data has been collected and processed, try to improve numbers by letting the whole hospital know about improvement goals that have been set and hope to be achieved.

Update the hospital on progress
Make the progress on both process and outcome measures publicly available so that staff and physicians can witness improvement.

Continuity is essential
Continue to use the checklist. Data collection may become less frequent as the checklist is accepted. A periodic check on progress will ensure that process measures stay on track and complications are minimized. Following the percentage of operations that use the checklist will help ensure adherence to it and the safety steps it embodies.