Audit of Compliance with the WHO Surgical Safety Checklist in the Orthopedic Operating Theatre at Benazir Bhutto Hospital

Abstract

The World Health Organization (WHO) Surgical Safety Checklist (SSC) has been shown to reduce peri-operative harm, but its real-world effectiveness is contingent on consistent, high-quality application. Global evidence indicates considerable variability in adherence, with the sign-out phase frequently showing the poorest compliance. Objective: To evaluate baseline SSC compliance in an orthopedic operating theatre, implement a targeted, low-cost intervention, and reassess compliance in a closed-loop audit. Methods: A closed-loop clinical audit was conducted at the Orthopedic Operating Theatre, Benazir Bhutto Hospital, Rawalpindi, Pakistan. In Cycle 1 (December 2024), 30 consecutive orthopedic surgeries were directly observed using a standardized SSC compliance tool. After the baseline assessment, a multifaceted intervention—comprising a department-wide educational session for surgeons, anesthetists, nurses, and residents; placement of laminated SSC posters at each operating table; and senior-staff verbal reinforcement and coaching—was implemented in February 2025. In Cycle 2 (June 2025), 30 new surgeries were observed by the same team using identical methods. Compliance for each SSC phase (sign-in, time-out, sign-out) was categorized as full (all items completed and verbalized), partial, or non-compliant. Descriptive statistics were applied to compare pre- and post-intervention proportions. Results: At baseline, full compliance was 40% for sign-in, 30% for time-out, and 20% for sign-out; overall, 30% of surgeries were fully compliant, 36% partially compliant, and 34% non-compliant. Following the intervention, full compliance increased to 80% (sign-in), 70% (time-out), and 65% (sign-out); overall, 72% of surgeries were fully compliant, 21% partially compliant, and 7% non-compliant. The most notable improvement occurred in the sign-out phase, which rose from 20% to 65% full compliance. Conclusion: A straightforward, low-cost intervention—combining education, visual reminders, and leadership engagement—more than doubled overall SSC full compliance in a high-volume orthopedic theatre within six months. Embedding such strategies into routine practice, alongside continuous monitoring and reinforcement, is likely essential to sustain improvements.