In Theatre
Vol. 21 No 3 | Spring 2019
Checklists for safe surgery in New Zealand

This article is 5 years old and may no longer reflect current clinical practice.

If I was doing a skydive, I would expect the team managing my jump to have undertaken safety checks and to have discussed the plan, so that everybody is clear on their role and the equipment needed to ensure a safe jump is in place.

Surely, I should expect the same from a team managing my surgery? Particularly if there is good evidence to show that undertaking simple checks and communicating well improve the likelihood of my operation being performed safely.

This article summarises the evidence for surgical checklists and briefings, and the New Zealand Health Quality & Safety Commission’s (the Commission’s) experience of implementing these tools nationally.

Surgical safety checklists

Checklists have long been used in industries where errors are unacceptable, such as aviation, the military, nuclear power and law enforcement.

Their applicability to healthcare was recognised and studied. Researchers observing the interaction between surgical team members described the negative impact of poor communication on performance and safety.1 2 3 The complexity of medical care, coupled with inherent limitations in human performance, make it critically important for surgical teams to speak up and express concerns – and to have tools to support that.4

In 2008 the World Health Organization (WHO) introduced the surgical safety checklist as a tool for clinicians to reinforce safety practices and foster better communication and teamwork between clinical disciplines.5

A 2014 systematic review noted checklists ‘have been shown to significantly improve patient outcomes subsequent to surgery, and therefore their use is being widely encouraged and accepted’.6 It also concludes that using the checklist improves teamwork and communication, and this may be behind the reduced rates of morbidity and mortality seen in the studies.

Implementation in New Zealand

The checklist was introduced as a national initiative in New Zealand by the Commission in 2011, as a response to an apparent high rate of perioperative adverse events compared with other countries. All (publicly funded) district health boards (DHBs) and a number of private surgical hospitals participated.

The program was relaunched in 2015 as Safe Surgery New Zealand (SSNZ), with a more explicit emphasis on its use to support improved teamwork and communication within surgical teams. This included nationally consistent use of a paperless poster checklist, a stronger focus on completion of all components of the three parts of the checklist (sign in, time out and sign out), and an emphasis on team engagement with each part of the checklist. The literature links a focus on these areas with improved team engagement and reduced complication rates.7 8

Since 2015/16, all DHBs have used direct observational audit to report quarterly on use of the three surgical checklist parts and the levels of team engagement with each part. The results are then made publicly available by the Commission.

Overall, national performance in each of the process measures has improved over time and currently sits in the mid-to-high 90 per cent region. However, there is considerable variation between DHBs and enduring issues with collecting the minimum number of required observation points in some DHBs.

Briefings and other tools

SSNZ also promotes other communication interventions to complement the checklist – particularly briefings at the start and end of the theatre list.

A start-of-list briefing takes five minutes or less and allows any issues that might affect the smooth running of the surgical list to be identified early. This includes any human factors that can lead to error, such as tiredness and fatigue, nutritional or emotional state, multi-tasking and loss of awareness.9

A briefing typically opens with team introductions, which include the name and role of each team member. Staffing matters are raised; anaesthetic safety checks are talked about; changes to the list or clarification about the list are discussed; equipment and instrumentation issues are communicated; and the time for the list is confirmed.

Briefings help to increase the safety culture of surgical teams.10 They can also result in efficiencies. For instance, a 2015 study in an orthopaedic setting reported a 72 per cent reduction in the rate of unexpected delays per case (from 23.1 per cent to 6.5 per cent).11

Debriefing occurs at the end of an operating session and involves all members of the theatre team assessing what they did well, what the challenges were and what they will do differently next time.12

There is anecdotal evidence that start-of-list briefings in particular are increasingly being held by New Zealand operating teams. (While national data are collected and reported, it is currently less reliable than data relating to Checklist use.) A ‘take five to save lives’ promotional campaign was held in late June 2019 to raise awareness and demonstrate the benefits of holding a briefing. All surgical teams were encouraged to undertake a briefing on that day. More than 60 surgical teams across public and private hospitals reported they had held a briefing on the day and of these respondents, more than 80 per cent said their surgical team typically does start-of-list briefings.

SSNZ is complemented by other national programs aiming to improve the safety and efficiency of care and to improve operating team culture. The NetworkZ program, which is being implemented across DHBs, involves surgical simulation and reinforces the use of checklists, briefings, teamwork and communication skills. The Royal Australasian College of Surgeons ‘Operating with Respect’ course aims to equip surgeons with the ability to self-regulate behaviour in the workplace and to moderate the behaviour of colleagues in order to build respect and strengthen patient safety.

Importance of culture change

It is hoped that over time these programs and other initiatives will support a culture in operating theatres that strengthens patient safety. Recent evidence suggests that operating room culture is associated with patient outcomes13and a common theme across studies relating to the checklist has been the need for implementation to be supported by an underlying safety culture change.

National surgical safety culture surveys held since 2015 are encouraging. A third iteration of the survey was conducted in 2019 and showed improvements since 2015 across almost all of the dimensions measured. Statistically significant improvements included a 30 per cent increase in participants saying team discussions (briefings and debriefings) are common and a 20 per cent increase in surgical teams always discussing the operative plan before incision. Improvements seen in clinical indicators such as the rate of deep vein thrombosis/pulmonary embolism may also be a reflection of the programs and culture associated with safe surgery in New Zealand.


The use of surgical checklists has been shown to reduce adverse events and improve patient outcomes. Start-of-list briefings and end-of-list debriefings support improved communication, better identification of recurring issues and a reduction in unexpected delays. A safety culture that encourages communication tools and speaking up gives a solid foundation for patient safety. There should be no question that these tools will be used when putting your wellbeing in the hands of others, regardless of the context.


  1. K Catchpole, A Mishra, A Handa, et al. Teamwork and error in the operating room: analysis of skills and roles. Ann Surg. 2008;247(4):699-706.
  2. CK Christian, ML Gustafson, EM Roth, et al. A prospective study of patient safety in the operating room. Surgery. 2006;139(2):159-73.
  3. DA Wiegmann, AW ElBardissi, JA Dearani, et al. Disruptions in surgical flow and their relationship to surgical errors: an exploratory investigation. Surgery. 2007;142(5):658-65.
  4. M Leonard, S Graham, D Bonacum. The human factor: The critical importance of effective teamwork and communication in providing safe care. Quality and Safety in Health Care. 2004;13:85-90.
  5. World Health Organization. 2008. Implementation manual: WHO surgical safety checklist (first edition). Geneva: World Health Organization.
  6. J Patel, K Ahmed, KA Guru, et al. An overview of the use and implementation of checklists in surgical specialities: A systematic review. International Journal of Surgery. 2014;12(12):1317-23.
  7. AP Ong, DA Devcich, J Hannam, et al. A ‘paperless’ wall-mounted surgical safety checklist with migrated leadership can improve compliance and team engagement. BMJ Qual Saf. 2016;25(12):971-6.
  8. E Mayer, N Sevdalis, S Rout, et al. 2015. Surgical checklist implementation project: The impact of variable WHO checklist compliance on risk-adjusted clinical outcomes after national implementation. Ann Surg. 2016;263(1):58-63.
  9. PA Brennan, DA Mitchell, S Holmes, et al. Good people who try their best can have problems: recognition of human factors and how to minimise error. Br J Oral Maxillofac Surg. 2016;54(1):3-7.
  10. KBMSL Leong, M Hanskamp-Sebregts, RA van der Wal, et al. Effects of perioperative briefing and debriefing on patient safety: a prospective intervention study. BMJ Open. 2017;7:e018367. doi: 10.1136/bmjopen-2017-018367.
  11. AL Jain, KC Jones, J Simon, et al. The impact of a daily pre-operative surgical huddle on interruptions, delays, and surgeon satisfaction in an orthopedic operating room: A prospective study. Patient Safety in Surgery. 2015;9:8.
  12. I Civil, C Shuker. Briefing and debriefing in one surgeon’s practice. ANZ J Surg. 2015;85:321-3.
  13. G Molina, WR Berry, SR Lipsitz, et al. Perception of safety of surgical practice among operating room personnel from survey data is associated with all-cause 30-day postoperative death rate in South Carolina. Ann Surg. 2017;266:658-66.

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