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Patient Safety in Surgery
Letter to the Editor
The WHO checklist: a global tool to prevent errors in surgery
Sukhmeet S Panesar*1, Kevin Cleary1, Aziz Sheikh2 and Liam Donaldson3
Address: 1National Patient Safety Agency (NPSA), Patient Safety Division, 4-8 Maple Street, London, W1T 5HD, UK, 2Division of Community
Health Sciences: GP Section, University of Edinburgh, 20 West Richmond Street, Edinburgh, EH8 9DX, UK and 3Department of Health Richmond
House 79 Whitehall, London, SW1A 2NS, UK
Email: Sukhmeet S Panesar* - email@example.com; Kevin Cleary - firstname.lastname@example.org; Aziz Sheikh - email@example.com;
Liam Donaldson - firstname.lastname@example.org
* Corresponding author
In this article, we welcome the adoption of the WHO surgical checklist to prevent errors in surgical
practice. We highlight the scale of the problem and discuss the adoption of this tool in the UK.
The increased complexity of healthcare has led to a corre-
sponding increase in the number of medical errors. A sig-
nificant proportion (up to 10%) of hospitalized patients
experience a patient safety incident and nearly half of
these are preventable.  Numerically, this translates to
just under 100,000 preventable patient deaths per year.
 Approximately 1 in 8 British individuals have a surgi-
cal procedure performed each year;  these typically
bringing them considerable benefits, but also subjecting
them to significant risk of potentially avoidable harm.
Significant advances have been made internationally
through the World Health Organization's World Alliance
for Patient Safety and through legislation to focus
increased attention on patient safety considerations. One
of the areas of particularly high priority is the creation of
patient safety reporting systems which aim to help iden-
tify patterns of errors and through so doing facilitate
learning and the formulation of harm reduction strate-
The UK has been spearheading the patient safety agenda
and is a pioneer in developing the first national repository
of patient safety events i.e. the Research and Learning
Service (RLS) database, which is maintained by the
National Patient Safety Agency (NPSA). This is now the
largest database of patient safety incidents in the world.
These incidents are arranged categorically. To date, the
NPSA has received in excess of 3 million reports  of
which 450,000 are surgically-related (see Figure 1).
The recently launched WHO Surgical Checklist is an
important development, which may help to prevent a
number of these surgical errors. Encouragingly, it has now
been adapted for use in England and Wales. 
One of the key error-prone areas that the surgical checklist
 can mitigate against is that of 'Wrong-Site Surgery.'
Wrong site or wrong patient incidents are rare, but the
consequences can result in considerable harm to the
patient. A recent study revealed 5,940 cases of wrong-site
surgery (2,217 wrong side surgical procedures and 3,723
wrong-treatment/wrong procedure errors) in 13 years. 
Our review of the RLS database (September 2007 – August
2008) revealed 26 (3.6%) cases of wrong patient, 62
(8.5%) of wrong side block, 150 (20.7%) of wrong side
marked on consent form, 78 (10.7%) of wrong side
marked on patient, 353 (48.6%) of wrong side marked on
theatre list, 11 (1.5%) of wrong site prosthesis and 46
Published: 28 May 2009
Patient Safety in Surgery 2009, 3:9doi:10.1186/1754-9493-3-9
Received: 11 May 2009
Accepted: 28 May 2009
This article is available from: http://www.pssjournal.com/content/3/1/9
© 2009 Panesar et al; licensee BioMed Central Ltd.
This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0),
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
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(6.3%) of wrong side surgery. These results are likely to be
a gross under-representation of the true number of these
events as reporting to the RLS is still far from complete. 
The important study by Haynes et al.  has demon-
strated that use of a simple checklist can substantially and
significantly reduce risk of morbidity and mortality asso-
ciated with surgery, and given the importance of this find-
ing in a field that tends to be characterised by relatively
little in the way of robust evidence, we have taken the pol-
icy decision to nationally implement routine use of this
approach.  Over the next year we expect all National
Health Service trusts to have adopted this very simple and
The authors declare that they have no competing interests.
SSP contributed to conception, design, analysis, interpre-
tation of data, and drafted the manuscript. KC, AS and LD
were involved in analysis and interpretation of data and
revised the manuscript critically for important intellectual
content. All authors read and approved the final manu-
SSP is a clinical advisor to the Medical Director, National
Patient Safety Agency (NPSA), KC is the Medical Director,
NPSA, AS is Professor of Primary Care, Research and
Development, University of Edinburgh and LD is the
Chief Medical Officer for England.
Vivian Tang, Clinical Advisor to the Medical Director, NPSA.
Bhavesh Patel, Information Analyst, NPSA.
VT and BP assisted with review of the incidents presented to the RLS data-
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Degree of harm for surgical incidents occurring in the Reporting and Learning System (RLS) at the NPSA between January 2005 and September 2008
Degree of harm for surgical incidents occurring in
the Reporting and Learning System (RLS) at the
NPSA between January 2005 and September 2008.