A Multinational Audit of WHO Surgical Safety Checklist Adherence in Low-Resource Settings
Abstract
A prospective multicentre observational audit evaluating real-world WHO Surgical Safety Checklist adherence, implementation gaps and perceived adverse-event prevention across low-resource settings.
The World Health Organization Surgical Safety Checklist is widely implemented to improve perioperative safety. However, uncertainty remains regarding how evidence of its effectiveness translates into real-world practice, particularly in low- and middle-income countries. This study evaluated checklist adherence, implementation gaps and the association between adherence and perceived adverse-event prevention.
A prospective multicentre observational audit was conducted across seven countries within The Operating Room Global collaborative network. The study incorporated direct observation and retrospective review of surgical procedures. A total of 1,132 surgical procedures were analysed. Associations were assessed using bivariate analysis, multivariable logistic regression and mixed-effects modelling to account for hospital-level clustering. Implementation barriers were also analysed qualitatively.
Perceived adverse-event prevention was reported in 77.1% of cases. Perfect checklist adherence occurred in only 4.1%. In conventional multivariable analysis, perfect adherence was associated with higher odds of perceived adverse-event prevention (OR 6.40; 95% CI 1.91–39.9; p<0.001), although the wide confidence interval indicated limited precision. After hospital-level clustering was accounted for, the association attenuated and was no longer statistically significant (OR 3.45; p=0.100; ICC=0.27). The model’s discriminative ability was modest (AUC=0.646).
Higher checklist adherence was associated with perceived adverse-event prevention in the initial analysis, but the relationship was strongly influenced by institutional context and was not statistically significant after hospital-level clustering. Training, infrastructure and workflow integration may support more effective checklist implementation in low-resource settings.
1,132 Surgical Procedures Across Seven Countries
The audit included 1,132 surgical cases from seven countries, providing a multicentre assessment of real-world WHO Surgical Safety Checklist implementation across diverse healthcare environments.
Only 4.1% Achieved Complete Checklist Adherence
Perfect adherence was defined as completion of every applicable checklist item for an individual case. Only 4.1% of procedures met this stringent definition.
77.1% Reported Perceived Adverse-Event Prevention
Perceived adverse-event prevention was reported in 77.1% of cases. Importantly, this was based on intraoperative team reporting and does not represent independently verified clinical outcomes.
OR 6.40 for Perfect Adherence
In multivariable logistic regression, perfect adherence was associated with higher odds of perceived adverse-event prevention (OR 6.40; 95% CI 1.91–39.9; p<0.001). The wide confidence interval indicates limited precision.
Association Was No Longer Statistically Significant
After accounting for hospital-level clustering, the association attenuated to OR 3.45 with p=0.100. This suggests that institutional context substantially influenced the observed relationship.
ICC = 0.27
The intraclass correlation coefficient of 0.27 indicated substantial between-hospital variability, reinforcing the importance of institutional and system-level factors.
72.9% Non-Adherence
Infection-risk assessment was the most frequently omitted Sign-In item, with a non-adherence rate of 72.9%, representing an important gap in checklist implementation.
66.8% Non-Adherence
Deep vein thrombosis prophylaxis assessment also demonstrated a substantial implementation gap, with 66.8% non-adherence.
Identity and Pulse Oximetry Were Almost Universal
Patient identity verification had only 0.6% non-adherence, pulse oximetry 0.4%, and informed consent 0.2%, demonstrating strong performance for several fundamental safety checks.
AUC = 0.646
The discriminative ability of checklist adherence for the self-reported primary outcome was modest, with an area under the receiver operating characteristic curve of 0.646.
Training and Resource Limitations
Qualitative analysis identified deficits in training and limitations in available resources as the principal barriers to effective checklist implementation.
Institutional Context Matters
The findings suggest that checklist completion alone may not explain differences in perceived safety benefit. Institutional practices, resources, training and workflow integration appear to be important determinants of implementation.
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Prospective Multicentre Observational Audit
The study evaluated real-world WHO Surgical Safety Checklist adherence across an international collaborative network and incorporated both direct intraoperative observation and retrospective record review.
1,132 Surgical Procedures
The final analysis included 1,132 surgical cases from seven countries and a range of healthcare settings and surgical specialties.
Perceived Adverse-Event Prevention
The primary outcome was derived from the checklist question asking whether an adverse event was prevented because of checklist use. It reflects subjective intraoperative team assessment and is not an independently adjudicated clinical outcome.
Overall, Phase and Item Levels
Adherence was evaluated at overall, checklist-phase and individual-item levels. Perfect adherence was defined a priori as completion of every applicable checklist item in a case.
Multilevel Analytical Approach
Analysis included bivariate testing, multivariable logistic regression, mixed-effects logistic regression with a hospital random intercept, and Firth penalized logistic regression as a sensitivity analysis for sparse perfect-adherence events.
Clustering Changed the Interpretation
The initial association between perfect adherence and perceived adverse-event prevention was no longer statistically significant after hospital-level clustering was incorporated, highlighting substantial institutional variability.
Outcome Was Subjective
Perceived adverse-event prevention was based on intraoperative team reporting rather than objectively verified patient outcomes. The findings therefore should not be interpreted as direct evidence that perfect adherence independently prevented clinical adverse events.
Observation and Record Review Not Separately Stratified
The proportion of cases obtained through direct observation versus retrospective documentation review was not formally stratified, and differences between the two collection methods were not independently assessed.
Important Covariates Were Unavailable
Patient-level variables including age, case complexity and urgency of surgery were not available in the dataset and therefore could not be incorporated into the statistical models.
TORG-IRB/Local Oversight
Ethical approval was obtained from The Operating Room Global Institutional Review Board (TORG-IRB), approval number TORG/IRB/002/2025, together with applicable local institutional approvals or exemptions.
Training, Infrastructure & Workflow
The findings support strengthening team training, infrastructure and integration of the checklist into routine surgical workflows, with implementation strategies responsive to institutional context.
Conflict of Interest & Funding
Conflict of Interest: No conflict of interest.
Funding: No funding received.
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CC BY 4.0
This work is licensed under the Creative Commons Attribution
4.0 International License.
DOI: 10.64573/torgj2605001
Volume 2 · Issue 2 · Special Issue · 2026
The Operating Room Global Journal (TORGJ).
ISSN 3105-3262.
Original Research.
DOI: 10.64573/torgj2605001.
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