Introduction of Surgical Safety Checklists in Ontario, Canada

Study Questions:

Did a policy encouraging universal use of surgical safety checklists result in improved outcomes in patients undergoing various types of operations in Ontario?


Use of surgical safety checklists has grown, but the evidence is largely observational. In particular, the effect of mandatory checklists on outcomes is uncertain. One hundred and one acute care hospitals in Ontario were surveyed to determine when surgical safety checklists were adopted. Claims data were then used to compare several outcomes—mortality, rate of surgical complications, length of hospital stay, and rates of hospital readmission and emergency department visits within 30 days after discharge—in patients undergoing various surgeries 3 months before and after adoption of the checklist.


The adjusted risk of death during a hospital stay or within 30 days after surgery was no different before and after implementation of the checklist (odds ratio [OR], 0.91; 95% confidence interval [CI], 0.80-1.03; p = 0.13). Similar findings were reported for surgical complications (OR, 0.97; 95% CI, 0.90-1.03; p = 0.29).


Implementation of the surgical safety checklist was not associated with significant reductions in mortality or complications following surgery in Ontario.


Once again, the value of another key innovation in quality improvement—in this case, use of surgical safety checklists—seems challenged by real-world data. This reminds us once again of the difficulty of implementing large-scale, generalizable quality improvement programs in health care. Lucian Leape, the editorialist for this paper and a national leader in the patient safety movement, seems to sum up the biggest limitation of this study—namely, it is unclear to what extent the checklists were a perfunctory exercise at these hospitals or whether they were actually incorporated meaningfully into care. Hopefully, this will provide motivation for institutions that are considering these surgical safety checklists to consider strategies for ensuring they are implemented by engaged clinicians and administrators. This takes leadership and organizational culture change. As David Urbach, the paper’s first author has noted: ‘It’s not as easy as a checklist.’

Keywords: Motivation, Quality Improvement, Safety, Patient Readmission, Canada, Emergency Service, Hospital, Organizational Culture, Patient Discharge, Leadership, Checklist, Length of Stay

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