Reducing risk in surgery

Patient safety during operative treatment

Checklists in surgical care

Row of red check marksThe use of checklists is becoming more common in healthcare settings. [REF]
Gawande, A. The Checklist Manifesto: How to get things right. New York, Metropolitan Books, 2010, p39.

For example, anaesthesiologists often use a checklist prior to the induction of anaesthesia. [REF]
Merchant, R., Bosenberg, C., Brown, K., Chartrand, D., Dain, S., Dobson, J., Kurrek, M., LeDez, K., Morgan, P., Penner, M., Shukla, R., Canadian Anaesthesiologists' Society. Guidelines to the practice of anesthesia, revised edition 2011. Can J Anesth, 2011; 58(1): [about 56 p.]. Appendix 3. Pre-anesthetic Checklist; [cited May 2011]; [about 1 screen]. Available from:

A checklist consists of a series of tasks or items relevant to a shared goal.

Think about it

Why use a checklist?

Checklists may:

  • Foster a patient safety mindset.
  • Improve communication across the patient care team.
  • Confirm the required tasks are completed.

Surgical safety checklists

There are worldwide efforts to improve the safety of operating rooms (ORs).

Following the launch of the World Health Organization's (WHO) Surgical Safety Checklist [REF]
World Health Organization, Surgical Safety Checklist, 2009 [cited May 2011]; [1 screen]. Available from:
, the Canadian Patient Safety Institute (CPSI), in collaboration with the University Health Network at the University of Toronto, adapted the WHO Surgical Safety Checklist for use in Canada.

While many healthcare facilities already have established safety practices, the checklist encourages a more comprehensive team approach with improved communication that may further decrease the risk of harm related to surgery.

Canadian Patient Safety Institute Surgical Safety Checklist 

Canadian Patient Safety Institute, Surgical Safety Checklist, 2009 [cited May 2011]; [1screen]. Available from:
  Three distinct procedural stages are identified on the CPSI Surgical Safety Checklist:
  1. Briefing — before induction of anaesthesia
  2. Time out — before skin incision
  3. Debriefing — before patient leaves OR

The checklist outlines key safety steps for members of the OR team — surgeons, anaesthesiologists, and nurses — to follow during each of the three stages. The "designated checklist coordinator" reads aloud each task or item and confirms that OR team members have performed or addressed each one before proceeding.

WHO checklist demonstration videos

View the following checklist demonstration videos from the World Health Organization. The first video demonstrates the correct way to perform the checklist. The second video illustrates what not to do.

Patient safety experts encourage customization of the surgical safety checklist to address the unique needs of a surgical discipline and practice environment.

The roles and responsibilities of each team member as they pertain to the checklist should be clear. Each team member is responsible to contribute to the completion of the checklist for each patient. If not performed satisfactorily, each individual risks being held accountable for his or her role in failing to comply with the checklist.

The following case examples illustrating each of the procedural stages illustrate surgical safety issues that might have been mitigated by properly using a surgical safety checklist.

Briefing case examples

Case: Patient information confirmed
Elderly female


An elderly nursing home resident with Alzheimer's disease falls and fractures her hip. Surgery is scheduled for later that day.
Consent form

Background continued

Consent for the procedure cannot be obtained as no family members are present, and the contact telephone number is incorrect. The emergency department (ED) nurse is aware the consent has not been signed, but she does not advise the orthopaedic surgeon.
Blurred image of pelvic region

Background continued

On arrival in the operating room (OR), the nurse reviews the pre-operative checklist. She inserts a check mark in the box beside "OR consent," even though no signed consent exists.

The surgeon does not personally verify the consent form before induction of anaesthesia.


Post-operatively, a family member complains that the family had not been advised of the planned procedure and no consent for surgery had been obtained.

Think about it

What steps should the team members have taken to confirm that consent for surgery was obtained?


  • The ED nurse should have advised the orthopaedic surgeon that there was no signed consent.
  • The OR nurse should have verified that consent for surgery existed before checking off the "OR consent" box on the pre-operative checklist.

Suggestions continued

  • The orthopaedic surgeon should have verified the consent for surgery when reviewing the patient's clinical documentation before induction of anesthesia.
  • The OR team should have verbally confirmed the consent for surgery during the briefing phase.

Lessons learned

Although other healthcare professionals may play a role in patient consent, the obligation to obtain informed consent generally rests with the physician who is to carry out the treatment or investigative procedure. [REF]
The Canadian Medical Protective Association, Consent: A guide for Canadian physicians, 2006. p7.

In situations where the patient is not capable of giving his or her own consent, the consent discussion must take place with the substitute decision-maker (for mentally incapacitated patients) or a parent or guardian (for minor patients).  [REF]

The Canadian Medical Protective Association, Consent: A guide for Canadian physicians, 2006. p5.


Case: Antibiotic prophylaxis
Prescription pills


A general surgeon performs an appendectomy on an obese, diabetic patient. No antibiotics are prescribed before the surgery.

The patient's appendix ruptures intra-operatively.

Despite the administration of antibiotics for three days following surgery, the patient develops serious complications including intra-abdominal abscess, sepsis, and multi-system failure.

The patient is left with permanent physical disabilities.


The patient initiated and won a legal action.

The court concluded that the general surgeon's failure to prescribe pre-operative antibiotics prior to removal of an inflamed appendix breached the standard of care.

Lessons learned

Had a surgical safety checklist been used, the OR team may have recognized during the briefing stage that antibiotics had not been administered.

Time-out case examples

Case: Surgeon, anaesthesiologist, and nurse verbally confirm
Two feet prepped for surgery with right ankle marked


Prior to right ankle surgery, an orthopaedic surgeon discusses the procedure with a patient and marks the site of surgery with a felt-tipped marker.

On the patient's arrival in the OR, the surgeon stands on the left side of the OR table. Without checking the marked site, she places a roll under the patient's left hip.

Surgery on ankle

Background continued

Following the surgeon's lead, the OR nurses help apply the tourniquet and then prep the left leg with antiseptic solution. The OR team does not verbally confirm the site of surgery.
Right female ankle with sutures

Background continued

Shortly after the skin incision on the left ankle, the anaesthesiologist advises the surgeon that she is operating on the wrong side. The surgeon promptly sutures the incision and proceeds to perform the intended surgery on the right ankle.

When the patient wakes up, the surgeon informs the patient about what happened.

No related long-term consequences result.

Think about it

What steps should the OR team members have taken to confirm the site of surgery before skin incision?


  • The orthopaedic surgeon should have visually checked the marked site before positioning the patient's hip.
  • The nurse should have personally checked the marked site before prepping the skin.
  • The OR team should have verbally confirmed the site during the time-out stage.

Lessons learned

Surgeons have a shared obligation to ensure they operate on the correct site, side, and level, and perform the intended procedure on the correct patient.

It is helpful to review the medical record and patient before the surgery and mark the correct surgical area.

Marking the site is particularly important for procedures that involve laterality (i.e. left versus right or medical versus lateral), multiple structures, or multiple levels (i.e. digit, skin lesion, or vertebra).


Debriefing case examples

Case: Nurse reviews with team:  instrument, sponge, needle counts
Tray of surgical instruments


A gynecologist performs an emergency laparotomy when bleeding difficulties are encountered during lysis of uterine adhesions.

Multiple sponges are placed into and removed from the abdominal cavity to control the bleeding, which stops with the application of pressure to the bleeding site.

Background continued

During the sponge count, the nurse reports that one sponge is missing. The gynecologist locates and removes the missing sponge and closes the wound.

Two days later, the patient develops a fever and abdominal distention. A CT scan reveals five sponges in the abdomen, which are then surgically removed.


An intra-operative abdominal X-ray prior to wound closure confirms there are no further sponges in the abdomen

Experts were of the opinion that the retained laparotomy sponges adversely affected the patient's pre-existing fertility problem.

Think about it

What else might the gynecologist have done when the nurse reported a missing sponge during the surgical count of the emergency laparotomy?


Steps the gynecologist could have done include:
  • perform a manual sweep of the abdomen to ensure no additional sponges remained
  • consider  performing an abdominal X-ray prior to wound closure, particularly due to the emergent nature of the laparotomy

Suggestions continued

Factors that increase the risk of retention of a foreign body include:
  • obesity
  • emergency procedures
  • unplanned changes to the procedure
  • surgeries involving multiple openings or multiple stages
  • poor visualization of the surgical site

Awareness of these risk factors should alert the OR team to the increased possibility of retention of a foreign body.

Lessons learned

Hospitals have policies and procedures that outline the items that need to be counted, the required documentation, and measures to be taken in the event of a discrepancy.

Case: Nurse reviews with team: Important intra-operative events
X ray image indicating foreign objects


A general surgeon encounters technical difficulties with an automatic EEA stapler during a low anterior resection with primary colorectal anastomosis.

Unaware that one of the stapler parts, the anvil, had been retained in the bowel, the surgeon manually sutures the anastomosis. The OR nurse reports the sponge and instrument counts as being correct.

The anvil later migrates, causing total disruption of the anastomosis.


The foreign body is subsequently removed surgically.

Subsequent colorectal anastomosis is unsuccessful, and the patient is left with two stomas.

Experts believed the anvil was a contributing factor in the disruption of the anastomosis.

Think about it

What safety measures could the OR team have taken before the patient left the OR to to ensure the anvil was not left in the colon?


  • As the person who placed the anvil into the proximal colon, it was the shared responsibility of the general surgeon to ensure it was not forgotten prior to manually suturing the anastomosis.
  • The OR nurse should have inspected the stapler and informed the general surgeon before the end of the procedure that part of the instrument was missing. This safety step is particularly important as the EEA stapler has several detachable parts.

Lessons learned

All surgical instruments should be accounted for and inspected for completeness, particularly if the instrument breaks, is disassembled during the procedure or has the potential to detach.

When an instrument does not functioning properly, it should be removed from use until it is repaired or replaced.