title: Attitudes towards the surgical safety checklist and factors associated with its use: A global survey of frontline medical professionals.
abstract: BACKGROUND
  The Surgical Safety Checklist (SSC) has been shown to reduce perioperative errors and complications and its implementation is recommended by the World Health Organisation (WHO). However, it is unknown how widely this intervention is used. We investigated attitudes and factors associated with use of WHO SSC in frontline medical professionals across the globe using a survey distributed through social networks.
  
  
  METHODS
  A survey of usage and opinions regarding the SSC was posted on the Facebook and Twitter pages of a not-for-profit surgical news website for one month (March 2013). Respondents were grouped into four groups based on their country's Gross National Income: high, upper middle, lower middle and low income. Univariate and multivariate analyses were performed to investigate how different factors were associated with the use of the SSC.
  
  
  RESULTS
  6269 medical professionals from 69 countries responded to the survey: most respondents were from lower middle (47.4%) countries, followed by: high (35.0%), upper middle (14.6%), and low (3.0%) income countries. In total, 57.5% reported that they used the WHO SSC perioperatively. Fewer respondents used the WHO SSC in upper middle, lower middle and low income countries (LMICs) compared to high income countries (43.5% vs. 83.5%, p < 0.001). Female (61.3% vs. 56.4% males, p = 0.001), consultant surgeons (59.6% vs. 53.2% interns, p < 0.001) and working in university hospitals (61.4% vs. 53.7% non-university hospitals, p < 0.001) were more likely to use the SSC. Believing the SSC was useful, did not work or caused delays was independently associated with the respondents reported use of the SSC (OR 1.22 95% CI 1.07-1.39; OR 0.47 95% CI 0.36-0.60; OR 0.64 95% CI 0.53-0.77, respectively).
  
  
  CONCLUSIONS
  This study suggests the use of the WHO SSC is variable across countries, especially in LMICs where it has the most potential to improve patient safety. Critical appraisal of the documented benefits of the WHO SSC may improve its adoption by those not currently using it.
authors.affiliation: Academic Department of Surgery, School of Cancer Sciences, University of Birmingham, Birmingham B15 2TH, UK.
authors.forename: Ravinder S
authors.initials: RS
authors.lastname: Vohra
authors.affiliation: Academic Surgical Unit, Castle Hill Hospital, Cottingham HU16 5JQ, UK.
authors.forename: Jonathan B
authors.initials: JB
authors.lastname: Cowley
authors.affiliation: Department of Vascular Surgery, Calderdale and Huddersfield NHS Foundation Trust, Huddersfield HD3 3EA, UK.
authors.forename: Neeraj
authors.initials: N
authors.lastname: Bhasin
authors.affiliation: Academic Vascular Surgical Unit, Hull York Medical School, Hull Royal Infirmary, Hull HU3 2JZ, UK.
authors.forename: Hashem M
authors.initials: HM
authors.lastname: Barakat
authors.affiliation: Yorkshire School of Surgery, The Department for Postgraduate Medical & Dental Education, Willow Terrace Road, University of Leeds, Leeds LS2 9JT, UK.
authors.forename: Michael J
authors.initials: MJ
authors.lastname: Gough
keywords: General surgery; Global health; Social media; Social networks