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National Patient Safety Agency

England and Wales to benefit from successful global safe surgery pilot which sees surgical deaths reduce by one third

Thursday 15 January 2009


The National Patient Safety Agency (NPSA) is issuing a patient safety alert today (Thursday 15 January). It requires all healthcare organisations to implement the WHO Surgical Safety Checklist for every patient undergoing a surgical procedure. The final implementation date is February 2010. This follows dramatic results from a year long global pilot of the WHO checklist in eight countries, including St Mary’s Hospital in London, which saw surgical deaths and complications reduce by one third when the checklist was used.


“The results from the pilot study are startling,” said Dr Atul Gawande, Associate Professor at Harvard School of Public Health and lead for the WHO Safe Surgery project. “They indicate that gaps in teamwork and safety practices in surgery are substantial in countries both rich and poor.  With the annual global volume of surgery now exceeding 234 million, the use of the WHO checklist could reduce deaths and disabilities by millions.  There should be no time wasted in introducing these checklists to help surgical teams do their best work to save lives.”


Sir Liam Donaldson, Chief Medical Officer for England and Chair of WHO World Alliance for Patient Safety, said: “The NPSA’s patient safety alert is critical for introducing safer surgery practices in the UK.  Our aim must be to reduce patient deaths and the level of surgical complications.  By giving our hospitals clear guidelines and a strict timeline for implementing the alert, we are highlighting the importance of patient safety.”


 Dr Kevin Cleary, Medical Director, NPSA, said: “The results of the study give clear evidence that a simple intervention leads to dramatic improvement in outcome for patients undergoing surgery.”


He continued: “Patients in the UK undergo more than eight million surgical procedures every year.  From 01 January 2007 to 31 December 2007 129,419 surgical incidents in England and Wales were reported to the NPSA’s Reporting and Learning System.  Over 1,000 resulted in severe harm and 271 resulted in death to the patient. The pilot study has shown we can do much better.”


Health Minister Lord Darzi, who prior to becoming a minister chaired a WHO working group that played a key role in developing the Safe Surgery Checklist, said: “The beauty of the surgical safety checklist is its simplicity and – as a practising surgeon – I would urge surgical teams across the country to use it.  Operating theatres are high-risk environments.  By using the checklist for every operation we are improving team communication, saving lives and helping ensure the highest standard of care for our patients.  The amazing results from the global pilot puts this beyond any doubt.” 


 View the NPSA’s Patient Safety Alert for the WHO Surgical Safety Checklist





Notes for editors:


Media enquiries to Amelia Lyons in the NPSA Press Office on 020 7927 9580 or amelia.lyons@npsa.nhs.uk.


WHO Safe Surgery Checklist – pilot study findings:

Eight pilot sites (Seattle, USA; Toronto, Canada; London, UK; Ifakara; Tanzania; Amman, Jordan; New Delhi, India; Manila, Philippines; and Auckland, New Zealand) used the checklist for between October 2007 to September 2008.


Data were collected from 7,688 patients, 3,733 before implementation of the checklist and 3,955 after the checklist was introduced.


The rate of major complication in the pilot study operating rooms fell from 11% in the baseline period to 7% after introduction of the checklist, a reduction of more than one third.


Patient deaths following surgical operations fell by more than 40% (from 1.5% to 0.8%) with introduction of the checklist.


Similar reductions in complications were seen in both the high income and lower income sites in the study, with rates falling from 10.3% to 7.1% and 11.7% to 6.8% respectively.


The National Patient Safety Agency is a Special Health Authority of the NHS. It encompasses three divisions; the National Research Ethics Service, the National Reporting and Learning Service and the National Clinical Assessment Service. Each has its own sphere of expertise to improve patient outcomes. The NPSA’s vision is to lead and contribute to improved, safe patient care by informing, supporting and influencing healthcare individuals and organisations.


Help for Trusts implementing the WHO Safe Surgery Checklist is available through the Patient Safety First Campaign for England, and has been provided since the Campaign went live on 15th September 2008.  For more information contact the campaign office on 0207 927 9346.