# Improving Surgical Safety Through Checklist Compliance: Lessons From a Clinical Audit in a Teaching Hospital

## TL;DR

A study in Sudan found that an educational intervention improved compliance with a surgical safety checklist, but challenges remain in verbalizing checklist items and changing staff perceptions.

## Contribution

The study demonstrates that a simple educational intervention can significantly improve compliance with the WHO Surgical Safety Checklist in a limited-resource setting.

## Key findings

- Baseline compliance with the checklist was low, but improved significantly after the intervention.
- Documentation and patient board completion also improved, but verbalization of checklist items remained weak.
- Staff cited lack of awareness, absence of responsibility, and increased workload as barriers to compliance.

## Abstract

Background

The World Health Organization (WHO) Surgical Safety Checklist (SSC) is a validated tool to improve perioperative safety and reduce preventable complications. Despite being introduced worldwide, compliance with the SSC remains inconsistent, especially in limited-resource settings. This study aimed to assess compliance with the SSC, identify barriers to its implementation, and evaluate the impact of an educational intervention at Omdurman Teaching Hospital, Omdurman, Sudan.

Methods

An observational clinical audit was conducted in the Department of Surgery at Omdurman Teaching Hospital between March and April 2025. A total of 100 operations were observed: 50 during the first audit cycle (baseline) and 50 during the second cycle (post-intervention). Data were collected using a structured tool adapted from the WHO SSC, recording whether checklist items were performed and/or verbalized during the Sign-In, Time-Out, and Sign-Out phases. An educational intervention, consisting of departmental seminars, posters, and reminders, was introduced between the two cycles. Staff feedback regarding barriers to SSC compliance was also obtained. Data were analyzed using IBM SPSS Statistics for Windows, Version 26 (Released 2018; IBM Corp., Armonk, NY, USA), with results expressed as frequencies and percentages.

Results

Baseline compliance with the SSC was suboptimal. Sign-In, Time-Out, and Sign-Out were performed in 60%, 52%, and 30% of cases, respectively, during Cycle 1. Following the intervention, compliance improved significantly: Sign-In to 86%, Time-Out to 80%, and Sign-Out to 88%. Documentation improved from 34% to 70%, while patient board completion rose from 28% to 64%. Verbalization of checklist items remained weak (e.g., Sign-Out read aloud: 0% vs. 12%). Staff cited lack of awareness (90%), absence of responsibility (75%), and perceptions of increased workload (60%) as key barriers.

Conclusion

Implementation of the WHO SSC at Omdurman Teaching Hospital demonstrated measurable improvements in compliance after a simple educational intervention. However, persistent gaps in verbalization and staff perceptions highlight the need for ongoing training, leadership engagement, and cultural change to sustain long-term adherence and strengthen surgical safety in Sudan.