# Ensuring Safe Surgery: A Closed-Loop Audit of the WHO Surgical Safety Checklist Practices

## TL;DR

This study shows that a simple training program significantly improved adherence to a surgical safety checklist at a hospital in Karachi, especially for elective surgeries.

## Contribution

The study demonstrates that an educational intervention can significantly improve compliance with the WHO Surgical Safety Checklist in a real-world hospital setting.

## Key findings

- Checklist compliance improved from 58.36% to 78.05% after an educational intervention.
- Antibiotic prophylaxis compliance increased from 0% to 85%, but blood preparation compliance declined.
- Hernioplasty and appendectomy showed the highest gains in checklist adherence.

## Abstract

Background and aim: The World Health Organization (WHO) developed the Surgical Safety Checklist (SSC) to support critical safety steps during surgeries. Although these standards were endorsed worldwide, many healthcare settings were not following them properly. This study aimed to assess the adherence to the WHO Surgical Safety Checklist at Sohail Trust Hospital, Karachi, and to identify which safety steps were often neglected during surgical procedures.

Methods: A prospective observational study was conducted from December 2024 to February 2025 at Sohail Trust Hospital, Karachi, under ethical approval #00126/25. A total of 120 surgical procedures were observed using a consecutive sampling technique. Compliance with each of the 18 recommended SSC items was recorded based on WHO guidelines. Data were collected across the following three surgical phases: before induction of anesthesia, before skin incision, and before the patient left the operating room. Descriptive statistics were used to summarize the data using SPSS version 26.0 (Armonk, NY: IBM Corp.), released in 2019.

Results: A total of 120 surgical procedures were audited, with 60 cases each in the pre- and post-intervention phases. Overall checklist compliance improved from 58.36% to 78.05% following an educational intervention (p=0.015, Wilcoxon signed-rank test). The greatest improvement was noted in antibiotic prophylaxis (0%-85%), while compliance for blood preparation in high-risk cases declined. Procedure-wise, hernioplasty and appendectomy showed the highest gains in adherence. The intervention demonstrated a large effect size (Cohen’s d=0.61).

Conclusion: A simple educational intervention significantly enhanced adherence to the WHO Surgical Safety Checklist, particularly in elective surgeries. These findings support the value of targeted training and continuous monitoring to improve surgical safety. Persistent gaps in emergency preparedness highlight the need for tailored strategies. Sustained efforts and team-based communication are essential to achieve long-term compliance and safer surgical outcomes.