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Ann Surg. 2013 Apr;257(4):633-9. doi: 10.1097/SLA.0b013e3182777fa4.

Implementation of the World Health Organization surgical safety checklist, including introduction of pulse oximetry, in a resource-limited setting.

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Department of Health Policy and Management, Harvard School of Public Health, Boston, MA 02115, USA.



To introduce the World Health Organization Surgical Safety Checklist into every operating room within a severely resource-limited hospital located in a developing country and to measure its impact on surgical hazards and complications.


The checklist has been shown to reduce surgical morbidity and mortality, but the ability to successfully implement the checklist program hospital-wide in lower income settings without basic resources is unknown.


We conducted a pre- versus postintervention study of the implementation of the checklist, including the introduction of universal pulse oximetry at a hospital in Chisinau, Moldova, where only 3 oximeters were available for their 22 operating stations. We supplied data-recording oximeters for all operating stations and trained a local checklist implementation team. The primary outcomes were process adherence, major complications, and rates of hypoxemia (SpO2 <90%). Propensity score weighing was conducted to adjust process and outcome measures. Regression models were used to evaluate adherence to process measures and hypoxemia trends over time.


Data from 2145 pre- and 2212 postintervention cases were collected. Adherence to all safety processes increased significantly from 0.0% to 66.9% (P < 0.001). After checklist implementation, the overall complication rate decreased from 21.5% to 8.8% (P < 0.001). Infectious and noninfectious complications decreased significantly after checklist implementation from 17.7% to 6.7% (P < 0.001) and from 2.6% to 1.5% (P = 0.018), respectively. The number of hypoxemic episodes lasting 2 minutes or longer per 100 hours of oximetry decreased from 11.5 to 6.4 (P < 0.002).


Successful hospital-wide Surgery Safety Checklist implementation can be achieved in a resource-limited setting and can significantly reduce surgical hazards and complications.

[Indexed for MEDLINE]

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