SAFETY CULTURE
Does the Surgical Safety Checklist need a co-pilot?
Published on
Jul 17, 2025
Surgical Endoscopy
Kjestine Emilie Møller, Jette Led Sørensen, Susanne Rosthøj, Patricia Trbovich, Teodor Grantcharov, Jeanett Strandbygaard
Overview
This observational study investigated the real-world use of the Surgical Safety Checklist in an elective gynecological operating room by comparing video-based assessments with documentation in patient electronic medical records. Despite widespread acceptance of the checklist as a tool for enhancing patient safety, the way its use is reported often differs from how it is actually implemented. Using the OR Black Box® to capture and analyze surgical procedures between August and October 2021, the study aimed to evaluate checklist adherence, engagement, and quality in practice, and to identify discrepancies between observed and reported use.
Results
Among the 45 surgeries analyzed, video review revealed full compliance with the Sign-in and Time-out phases, but only 80% compliance with Sign-out. Team engagement during checklist use varied, with an average engagement score of 76%, ranging from 45% to 94%. Notably, the quality of checklist completion was significantly lower when assessed via video (47%) compared to what was documented in electronic medical records (89%). This substantial gap suggests that the checklist may often be reported as completed more thoroughly than it actually is in practice, underscoring the need for improved accuracy in safety reporting and greater emphasis on proper checklist use.
Peer-reviewed Research
