A Multinational Audit of WHO Surgical Safety Checklist Adherence in Low-Resource Settings
Article DOI: https://doi.org/10.64573/torgj2605001
Authors: Adebusola Adenike Owokole1, 2,18*, Nurhusen Riskey Arefayne1,13,14, Nigussie Tefera Habiteyohannis¹,³, Hailemariam Getachew Tesema¹,⁴, Kevin Miko Maestrado Buac¹,⁵, Alazar Menbere Haile¹,⁶, Kübra Özpınar¹,⁷, Demeke Yilkal Fentie¹, 13, 14, John Amani¹,⁸, Clement Okyere Sefa¹,⁹, Sayed Ahbab Hussain¹,¹⁰, Arshad Ali M. Bashir¹,¹⁰, Bedlu Tilahun Amtate¹,¹¹, Getachew Mekete Deress¹,¹², Mesfin Shimelash Abeje¹,¹³, Samuel Wodajo Mamo¹,¹¹, Nigat Amsalu Addis¹, ¹³,14, Amare Belete Getahun¹,13,¹⁴, Joshua Olaopin¹,¹⁵, Abdulkarim Abdulwahab¹,¹⁶, Firdausi Yusha’u Muhammad¹,¹⁶, Ahmed Shuaibu Tsafi¹,¹⁷
| ¹ The Operating Room Global (TORG) ² The Robotic Global Surgical Society (TROGSS) ³ Debre Birhan Comprehensive Specialized Hospital, Ethiopia ⁴ Partners in Health, Sierra Leone; Dilla University, Ethiopia ⁵ The University of Hong Kong, School of Public Health, Li Ka Shing Faculty of Medicine, Hong Kong SAR, China ⁶ Department of Orthopedics and Trauma Surgery, College of Health Sciences, Addis Ababa University, Ethiopia ⁷ Department of Obstetrics and Gynecology, Dr. Yaşar Eryılmaz Doğubeyazıt State Hospital, Ağrı, Turkey ⁸ Global Maternity, Tanzania ⁹ FOCOS Orthopedic Hospital, Ghana ¹⁰ District Head Quarter Hospital Parachinar / Indus Hospital Network, Pakistan ¹¹ Debre Berhan Comprehensive Specialized Hospital, Ethiopia ¹² Debre Tabor Comprehensive Specialized Hospital, Ethiopia ¹³ University of Gondar College of Medicine and Health Sciences, Ethiopia ¹⁴ University of Gondar Comprehensive Specialized Hospital, Ethiopia ¹⁵ Babcock University Teaching Hospital, Ilishan-Remo, Ogun State, Nigeria ¹⁶ Aminu Kano Teaching Hospital, Kano, Nigeria ¹⁷ Federal Medical Centre Nguru, Nigeria ¹8 University of Limerick (UL) Hospitals, Ireland. |
Cite:
- APA (7th edition): Owokole, A. A., Arefayne, R. N., Habiteyohannis, N. T., Tesema, H. G., Buac, K. M. M., Haile, A. M., Özpınar, K., Fentie, D. Y., Amani, J., Sefa, C. O., Hussain, S. A., Bashir, A. A. M., Amtate, B. T., Deress, G. M., Abeje, M. S., Mamo, S. W., Addis, N. A., Getahun, A. B., Olaopin, J., Abdulwahab, A., Muhammad, F. Y., & Tsafi, A. S. (2026, May 7). A multinational audit of WHO surgical safety checklist adherence in low-resource settings. The Operating Room Global Journal (TORGJ), 2(2). https://doi.org/10.64573/torgj2605001
- Harvard: Owokole, A.A., Arefayne, N.R., Habiteyohannis, N.T., Tesema, H.G., Buac, K.M.M., Haile, A.M., Özpınar, K., Fentie, D.Y., Amani, J., Sefa, C.O., Hussain, S.A., Bashir, A.A.M., Amtate, B.T., Deress, G.M., Abeje, M.S., Mamo, S.W., Addis, N.A., Getahun, A.B., Olaopin, J., Abdulwahab, A., Muhammad, F.Y. and Tsafi, A.S., 2026. A multinational audit of WHO surgical safety checklist adherence in low-resource settings. The Operating Room Global Journal (TORGJ), 2(2). Published 7 May. Available at: https://doi.org/10.64573/torgj2605001
- Vancouver: Owokole AA, Arefayne NR, Habiteyohannis NT, Tesema HG, Buac KMM, Haile AM, Özpınar K, Fentie DY, Amani J, Sefa CO, Hussain SA, Bashir AAM, Amtate BT, Deress GM, Abeje MS, Mamo SW, Addis NA, Getahun AB, Olaopin J, Abdulwahab A, Muhammad FY, Tsafi AS. A multinational audit of WHO surgical safety checklist adherence in low-resource settings. The Operating Room Global Journal (TORGJ). 2026 May 7;2(2). https://doi.org/10.64573/torgj2605001
- MLA (9th edition): Owokole, Adebusola Adenike, et al. “A Multinational Audit of WHO Surgical Safety Checklist Adherence in Low-Resource Settings.” The Operating Room Global Journal (TORGJ), vol. 2, no. 2, 7 May 2026, https://doi.org/10.64573/torgj2605001
- Chicago (Author-Date): Owokole, Adebusola Adenike, Nurhusen Riskey Arefayne, Nigussie Tefera Habiteyohannis, Hailemariam Getachew Tesema, Kevin Miko Maestrado Buac, Alazar Menbere Haile, Kübra Özpınar, Demeke Yilkal Fentie, John Amani, Clement Okyere Sefa, Sayed Ahbab Hussain, Arshad Ali M. Bashir, Bedlu Tilahun Amtate, Getachew Mekete Deress, Mesfin Shimelash Abeje, Samuel Wodajo Mamo, Nigat Amsalu Addis, Amare Belete Getahun, Joshua Olaopin, Abdulkarim Abdulwahab, Firdausi Yusha’u Muhammad, and Ahmed Shuaibu Tsafi. 2026. “A Multinational Audit of WHO Surgical Safety Checklist Adherence in Low-Resource Settings.” The Operating Room Global Journal (TORGJ) 2 (2), May 7. https://doi.org/10.64573/torgj2605001
*Corresponding Author:
Prof. Adebusola Adenike Owokole
[email protected]
Declaration:
Authors’ Contribution:
All authors contributed substantially to the study conception, design, data collection, analysis, manuscript preparation, and final approval of the submitted version. Prof. Adebusola Adenike Owokole led the overall study supervision, ensured regulatory compliance, coordinated site documentation across participating institutions, and reviewed all stages of the study; Asst. Prof. Nurhusen Riskey Arefayne conceptualized the study; Dr. Nigussie Tefera Habiteyohannis coordinated project implementation and supported site-level engagement and data collection processes; Mr. Hailemariam Getachew Tesema and Dr. Kevin Miko Maestrado Buac contributed to the development and design of the audit tool; Dr. Alazar Menbere Haile conducted the statistical analysis, data interpretation, and visualization of findings; Asst. Prof. Demeke Yilkal Fentie developed the audit proposal and contributed to the conceptual framework of the study; Dr. Kübra Özpınar led the manuscript drafting, integration of sections, literature synthesis, and overall writing of the manuscript; Data collection across participating institutions was conducted byDr. John Amani, Clement Okyere Sefa, Sayed Ahbab Hussain, Arshad Ali M. Bashir, Bedlu Tilahun Amtate, Getachew Mekete Deress, Dr. Mesfin ShimelashAbeje, Dr. Samuel Wodajo Mamo, Dr. Nigat Amsalu Addis, Amare Belete Getahun, Dr. Joshua Olaopin, Abdulkarim Abdulwahab, Firdausi Yusha’u Muhammad, and Ahmed Shuaibu Tsafi. These contributors were responsible for data collection, validation, and submission using the standardized audit tool.
Conflict of Interest:
No conflict of interests.
Funding:
No funding received by the authors.
| Article History: |
| Received: 26-04-2026 Accepted: 06-05-2026 |
| Available Online: 07-05-2026 |
| QR Code Access to this Article |
| ABSTRACT |
| Background: The World Health Organization Surgical Safety Checklist (WHO SSC) is a widely implemented intervention to improve perioperative safety. However, the extent to which these findings can be extrapolated to the real-world context is uncertain, particularly in low and middle-income countries (LMICs). The objective of this study was to evaluate the adherence to checklists, identify any implementation gaps, and assess the association between checklist adherence and perceived adverse event prevention across a range of healthcare settings. Methods: A prospective multicenter observational audit was conducted across seven countries within The Operating Room Global (TORG). The study incorporated both direct observation and retrospective review of surgical procedures. Ethical approval was obtained from The Operating Room Global Institutional Review Board (TORG-IRB), approval number TORG/IRB/002/2025 and local institutions. The analysis encompassed a total of 1,132 surgical procedures. The degree to which checklist adherence was demonstrated was evaluated at the overall, phase, and item levels. The primary outcome was a self-reported measure of perceived adverse event prevention, based on intraoperative team reporting, and does not represent objectively verified clinical outcomes. The associations were evaluated using bivariate analysis and multivariable logistic regression, with mixed-effects modelling to account for hospital-level clustering. A qualitative analysis was also conducted on the implementation barriers that were encountered. Results: Perceived adverse event prevention was reported in 77.1% of cases. Perfect checklist adherence was observed in 4.1% of cases and was associated with higher odds of perceived adverse event prevention in multivariable analysis (odds ratio [OR]: 6.40; 95% confidence interval [CI]: 1.91-39.9; p < 0.001), although the wide confidence interval suggests limited precision. However, this association was attenuated and no longer statistically significant after accounting for hospital-level clustering (OR: 3.45; p = 0.100; ICC = 0.27), indicating substantial variability between hospitals. Adherence to the checklist varied across the phases of the study, with substantial gaps in key safety items such as infection risk assessment (72.9%) and DVT prophylaxis (66.8%). The discriminative ability of checklist adherence was modest (AUC = 0.646). The qualitative findings identified training deficits and resource limitations as the primary barriers. Conclusions: While higher checklist adherence was associated with perceived adverse event prevention, this relationship appears to be strongly influenced by the institutional context. However, this association was not statistically significant after accounting for hospital-level clustering, suggesting that institutional and system-level factors may play a more critical role than adherence alone. Strengthening training, infrastructure, and workflow integration may support improved checklist implementation in low-resource settings. These findings should be interpreted in light of the subjective nature of the outcome measure. Keywords: Low-Resource Countries; Patient Safety; Surgical Safety Checklist; Global Surgery; Quality Improvement; Perioperative Safety |
Download Full Text Below