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Database of Abstracts of Reviews of Effects (DARE): Quality-assessed Reviews [Internet]. York (UK): Centre for Reviews and Dissemination (UK); 1995-.

Database of Abstracts of Reviews of Effects (DARE): Quality-assessed Reviews [Internet].

Systematic review of safety checklists for use by medical care teams in acute hospital settings: limited evidence of effectiveness

HC Ko, TJ Turner, and MA Finnigan.

Review published: 2011.

CRD summary

This review of safety checklists in acute hospital settings found some benefits for using safety checklists to improve protocol adherence and patient safety, but recommended this should be treated with caution due to the high risk of bias. These are suitably cautious conclusions but are limited by possible language bias and a lack of detail on some review methods.

Authors' objectives

To evaluate whether use of paper-based safety checklists, compared to not using checklists, improved patient safety in acute hospital settings.


MEDLINE, CINAHL, EMBASE and The Cochrane Library were searched for studies published in English between 1980 and September 2009. Search terms were reported. Reference lists of the included studies were searched.

Study selection

Eligible studies investigated care that included use of paper-based checklists of safety concerns applied to patients by medical care teams (including a medical clinician or surgeon) compared with care provided without checklists. Eligible studies were in acute hospital settings. Any patient-relevant clinical outcomes were eligible. Studies were excluded where the checklist was not paper-based (for example, electronic), was part of a multifaceted quality improvement programme or was not the primary tool to drive improvements.

The included studies were based in four clinical settings: intensive care units, emergency departments, surgery and multi-departmental acute care. Interventions included daily patient goal sheets that were completed by staff, checklists and training for surgeons, intensive care unit checklists, post-endoscopy checklists and medical checklists, forms and reminders. Control groups were standard care without use of checklists.

Studies were selected and appraised by two reviewers independently in consultation with colleagues.

Assessment of study quality

Study quality was assessed using a checklist developed for cohort studies by the Centre for Clinical Effectiveness, Southern Health. This included 19 questions on study aims and design, blinding, outcome assessment, baseline similarity, study adequately powered, loss to follow-up and appropriate statistical analysis. An overall risk of bias assessment was then made.

The authors did not report how many reviewers performed the quality assessment.

Data extraction

Details of interventions, settings and outcomes were extracted for each study. Authors were contacted for missing data.

The authors did not report how many reviewers performed data extraction.

Methods of synthesis

Results were presented in a narrative summary grouped by clinical setting.

Results of the review

Nine cohort studies with historical controls (at least 9,943 participants; numbers not reported in three studies) were included. Study quality was low to moderate. Conflict of interest was not reported in most studies, the study design was open to bias, methods of participant selection and allocation concealment and blinding were mostly unclear, data collection methods were only partly explained and some studies used partly appropriate analysis methods.

Intensive care units (five studies): All studies set in intensive care units used different types of checklists, reported different outcomes and were at high risk of bias. One study reported a significant decrease in length of stay for the checklist group and another reported that the percentage of ventilator days per week when patients received all four care processes increased significantly from 30% before to 96% during the intervention. In another study only four domains from the checklist were assessed and compared and this found significantly better results during the intervention period for use of physical therapy and transfer to telemetry. Two other studies reported reductions in length of stay but did not report whether they were statistically significant.

Emergency departments (two studies): Both studies set in emergency departments were at high risk of bias. One used a safety checklist for patients with an indwelling urinary tract catheter and found appropriate use of catheters increased following the intervention but this was not statistically significant. There was a significant increase in physician orders for catheter placement. In a study of a post-endoscopy checklist there was a significant decrease in length of stay with use of the checklist.

Surgery (one study): This study had a moderate risk of bias. It assessed a 19-item surgical safety checklist in eight hospitals in eight countries. Rates of major complications, deaths in hospital, surgical site infections and unplanned reoperations fell significantly during the intervention period. Process adherence to correct surgical protocols that comprised six safety measures showed that the intervention significantly improved five of the six measures. Only the outcome of ensuring the presence of at least two peripheral intravenous catheters or a central venous catheter before incision in cases with an estimated blood loss of 500mL or more did not improve.

Acute care (one study): This study had a high risk of bias. It found hospitals that used a checklist administered appropriate antibiotics within eight hours for patients with pneumonia significantly more often than hospitals without the checklist.

Authors' conclusions

There was no high level evidence showing the effectiveness of safety checklists. There was evidence to suggest some benefits for using safety checklists to improve protocol adherence and patient safety, but this should be treated with caution due to the high risk of bias.

CRD commentary

This review specified inclusion criteria for the interventions, setting and outcomes and broad criteria for study design. The search was limited to published studies in English, which the authors acknowledged as a potential limitation of the review. To reduce mistakes or bias the studies were selected by two people independently; it was unclear whether similar steps were taken for data extraction and quality assessment. Data quality was assessed, reported fully and considered when discussing the study results. Differences between the studies meant that a narrative presentation of results was appropriate.

The authors conclusions are suitably cautious given the flaws in the evidence. Possible language bias and a lack of detail on some review methods were limitations of this review.

Implications of the review for practice and research

Practice: The authors stated that health services that planned to implement safety checklists should use an evidence-based approach to selecting, designing and validating checklists and/or checklist items. Resource use such as staff time and funding to provide training and education for using the checklists should be considered.

Research: The authors stated a need for more high quality clinical trials to compare different checklist designs and content within the same settings.


No external funding.

Bibliographic details

Ko HC, Turner TJ, Finnigan MA. Systematic review of safety checklists for use by medical care teams in acute hospital settings: limited evidence of effectiveness. BMC Health Services Research 2011; 11: 211. [PMC free article: PMC3176176] [PubMed: 21884618]

Indexing Status

Subject indexing assigned by NLM


Checklist /standards; Female; Hospitals, Special; Humans; Intensive Care /standards; Male; Patient Care Team /standards; Patient Safety; Quality of Health Care; Safety Management /standards; Treatment Outcome; Victoria



Database entry date


Record Status

This is a critical abstract of a systematic review that meets the criteria for inclusion on DARE. Each critical abstract contains a brief summary of the review methods, results and conclusions followed by a detailed critical assessment on the reliability of the review and the conclusions drawn.

CRD has determined that this article meets the DARE scientific quality criteria for a systematic review.

Copyright © 2014 University of York.

PMID: 21884618


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