Incorporating an oral checklist into surgical procedures slashed complications and death rates by more than a third, researchers report after a yearlong global study.

“The results are startling,” observes senior author Atul A. Gawande, MD, MPH, associate professor at the Harvard School of Public Health (HSPH), in Boston.

The 19-item checklist requires oral confirmation that basic steps have been taken to ensure the safe delivery of anesthesia, prophylaxis against infection, and other essential practices. It incorporates the conventional “time out” before incision and brackets it with pauses before anesthesia is administered and before the patient is taken out of the operating room.

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This prospective study was a collaboration between HSPH and the World Health Organization. Eight hospitals — seven of them urban — in eight countries participated. To create a baseline, researchers gathered data on 3,733 consecutive patients undergoing noncardiac surgery. Then they introduced the checklist for the next 3,955 consecutive operations and compared complication rates after 30 days (N Engl J Med. 2009;360:491-499).

There were no significant demographic or procedural differences between the two phases of the study, but the aggregate complication rate dropped from 11.0% at baseline to 7.0% after introduction of the checklist. All eight sites reported a reduction. The total in-hospital death rate dropped from 1.5% to 0.8%.

“The checklist had a visible impact at every site in the study,” notes lead author Alex B. Haynes, MD, MPH, a research fellow at HSPH. “Even many clinicians who were initially skeptical of the idea became advocates once they saw the benefits to safety and consistency of care.”

A formatted copy of the checklist is available with the report at, accessed March 6, 2009.