Reducing surgical mortality in Scotland by use of the WHO Surgical Safety Checklist

G. Ramsay, A. B. Haynes, S. R. Lipsitz, I. Solsky, J. Leitch, A. A. Gawande, M. Kumar (Corresponding Author)

Research output: Contribution to journalArticlepeer-review

69 Citations (Scopus)
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BACKGROUND: The WHO Surgical Safety Checklist has been implemented widely since its launch in 2008. It was introduced in Scotland as part of the Scottish Patient Safety Programme (SPSP) between 2008 and 2010, and is now integral to surgical practice. Its influence on outcomes, when analysed at a population level, remains unclear.

METHODS: This was a population cohort study. All admissions to any acute hospital in Scotland between 2000 and 2014 were included. Standardized differences were used to estimate the balance of demographics over time, after which interrupted time-series (segmented regression) analyses were performed. Data were obtained from the Information Services Division, Scotland.

RESULTS: There were 12 667 926 hospital admissions, of which 6 839 736 had a surgical procedure. Amongst the surgical cohort, the inpatient mortality rate in 2000 was 0·76 (95 per cent c.i. 0·68 to 0·84) per cent, and in 2014 it was 0·46 (0·42 to 0·50) per cent. The checklist was associated with a 36·6 (95 per cent c.i. -55·2 to -17·9) per cent relative reduction in mortality (P < 0·001). Mortality rates before implementation were decreasing by 0·003 (95 per cent c.i. -0·017 to +0·012) per cent per year; annual decreases of 0·069 (-0·092 to -0·046) per cent were seen during, and 0·019 (-0·038 to +0·001) per cent after, implementation. No such improvement trends were seen in the non-surgical cohort over this time frame.

CONCLUSION: Since the implementation of the checklist, as part of an overall national safety strategy, there has been a reduction in perioperative mortality.

Original languageEnglish
Pages (from-to)1005-1011
Number of pages7
JournalBritish Journal of Surgery
Issue number8
Early online date16 Apr 2019
Publication statusPublished - Jul 2019

Bibliographical note

R. Munro and R. Black of NHS National Services Scotland, UK, provided data intelligence. B. Robson helped review this paper; A. Longmate was involved in the preliminary design of this study; J. Ingram, J. Ferbrache and SPSP managers from health boards in Scotland provided some of the information on surgical checklist implementation practices at hospitals across NHS Scotland. Data, analytical methods and study materials used may be made available to other researchers on request. The lead author affirms that the manuscript is an honest, accurate and transparent account of the study being reported. No important aspects of the study have been omitted. Any discrepancies from the study as planned (and, if relevant, registered) have been explained. This study was not funded by any individual or group. The Research Governance Department of the University of Aberdeen sponsored this project and supported the application through ethical review and data management.

Disclosure: A.A.G. has received royalties from multiple publishers for writing on improving healthcare, including through use of checklists: Objetiva, Sextante (Brazil); Profile Books Ltd (British Commonwealth); Cheers Publishing Company, Commonwealth Publishing Co (People's Republic of China); Jesenski & Turk, Mizaik Knjiga, Mozaik Knjiga (Croatia); Dokoran (Czech Republic); Lindhart og Rinhoft Forlag (Denmark); Pilgrim Group (Estonia); Editions Moyen‐Courrier, Fayard, Libraire Arthème Fayard, Moyen‐Courrier (France); Radarami (Georgia), S Fischer, Verlagsgruppe Random House (Germany); Crete University Press (Greece); Tericam Kindo (Hungary); Mehta Publishing House, Penguin Random House Books (India); Gramedia Pustaka Utama, Serambi Ilmu Semesta (Indonesia); Arjmand Press (Iran); Am Oved, Modan (Israel); Einaudi Editore (Italy); Misuzu Shobo, Shinyusha Co Ltd (Japan); Janis Roze Publishers (Latvia); Vaga (Lithuania); Mime Forlag (Norway); Magnum, Znak (Poland); Lua de Papel (Portugal); Codecs, Grup Media Litera, Litera, Streamland Ltd (Romania); Slovant Publishers (Slovakia); Mladinska Knjiga (Slovenia); Antoni Bosch Editor, Editorial Empuries, Galaxia Gutenberg (Spain); Asa Editore, Bookie Publishing House, Book21, Sosoh Publishing (South Korea); Volante (Sweden); Alpina, AST (Russia); Matichon, Openworlds (Thailand); Arbeiderspers, Nieuwezijds, Uitgeverij De Arbeiderspers, Uitgeverij Nieuwezijds (the Netherlands); Domingo, Koton Kitap (Turkey); Verlagsgruppe Vivat (Ukraine); CBS Television, Henry Holt, Houghton Mifflin, Harvard Business School Press, McGraw Hill, Pearson Publishing, Public Broadcasting Service, Picador USA (USA), First News‐Tn Viet Publishing Co, Suc Manh Ngoi But Co (Vietnam); and Harper Collins (World). The authors declare no other conflict of interest.


  • surgical mortality
  • WHO surgical safety checklist


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