title: Effects of the introduction of the WHO "Surgical Safety Checklist" on in-hospital mortality: a cohort study.
abstract: OBJECTIVE
  To evaluate the effect of implementation of the WHO's Surgical Safety Checklist on mortality and to determine to what extent the potential effect was related to checklist compliance.
  
  
  BACKGROUND
  Marked reductions in postoperative complications after implementation of a surgical checklist have been reported. As compliance to the checklists was reported to be incomplete, it remains unclear whether the benefits obtained were through actual completion of a checklist or from an increase in overall awareness of patient safety issues.
  
  
  METHODS
  This retrospective cohort study included 25,513 adult patients undergoing non-day case surgery in a tertiary university hospital. Hospital administrative data and electronic patient records were used to obtain data. In-hospital mortality within 30 days after surgery was the main outcome and effect estimates were adjusted for patient characteristics, surgical specialty and comorbidity.
  
  
  RESULTS
  After checklist implementation, crude mortality decreased from 3.13% to 2.85% (P = 0.19). After adjustment for baseline differences, mortality was significantly decreased after checklist implementation (odds ratio [OR] 0.85; 95% CI, 0.73-0.98). This effect was strongly related to checklist compliance: the OR for the association between full checklist completion and outcome was 0.44 (95% CI, 0.28-0.70), compared to 1.09 (95% CI, 0.78-1.52) and 1.16 (95% CI, 0.86-1.56) for partial or noncompliance, respectively.
  
  
  CONCLUSIONS
  Implementation of the WHO Surgical Checklist reduced in-hospital 30-day mortality. Although the impact on outcome was smaller than previously reported, the effect depended crucially upon checklist compliance.
authors: Division of Perioperative Care and Emergency Medicine, University Medical Centre Utrecht, Utrecht, NL. w.a.vanklei@umcutrecht.nl
authors: W A
authors: WA
authors: van Klei
authors: R G
authors: RG
authors: Hoff
authors: E E H L
authors: EE
authors: van Aarnhem
authors: R K J
authors: RK
authors: Simmermacher
authors: L P E
authors: LP
authors: Regli
authors: T H
authors: TH
authors: Kappen
authors: L
authors: L
authors: van Wolfswinkel
authors: C J
authors: CJ
authors: Kalkman
authors: W F
authors: WF
authors: Buhre
authors: L M
authors: LM
authors: Peelen
mesh_terms: D000328:Adult; D000368:Aged; D057189:Checklist / Q000592:standards* / Q000706:statistics & numerical data; D015331:Cohort Studies; D005260:Female; D019983:Guideline Adherence / Q000706:statistics & numerical data / Q000639:trends; D006284:Health Plan Implementation / Q000458:organization & administration; D017052:Hospital Mortality / Q000639:trends*; D006785:Hospitals, University; D006801:Humans; D008297:Male; D008875:Middle Aged; D009426:Netherlands; D016017:Odds Ratio; D017063:Outcome Assessment, Health Care / Q000706:statistics & numerical data; D061214:Patient Safety / Q000592:standards*; D012189:Retrospective Studies; D015996:Survival Rate; D014600:Utilization Review; D014944:World Health Organization