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Head To Head Head to Head

Is WHO’s surgical safety checklist being hyped?

BMJ 2019; 366 doi: (Published 05 August 2019) Cite this as: BMJ 2019;366:l4700
  1. David R Urbach, professor of surgery and health policy, management, and evaluation1,
  2. Justin B Dimick, professor and chair of surgery2,
  3. Alex B Haynes, associate chair for investigation and discovery3,
  4. Atul A Gawande, professor of surgery4
  1. 1University of Toronto, Toronto, Ontario, Canada
  2. 2University of Michigan, Ann Arbor, MI, USA
  3. 3Department of Surgery and Perioperative Care, Dell Medical School of the University of Texas at Austin, Austin, TX, USA
  4. 4Harvard Medical School, Boston, MA, USA
  1. Correspondence to: Justin B Dimick jdimick{at}, Alex B Haynes alex.haynes{at}

Studies show that the World Health Organization’s surgery checklist saves lives around the world, say Alex Haynes and Atul Gawande. But David Urbach and Justin Dimick argue that there’s not enough evidence to say for sure

Yes—David R Urbach, Justin B Dimick

Extraordinary claims, Carl Sagan used to say, require extraordinary evidence. The famed astronomer and science communicator was advocating skepticism around pseudoscientific and paranormal phenomena such as astrology and divination, but it’s reasonable to apply a similarly high standard of scientific evidence to the World Health Organization’s surgical safety checklist.

Checklists, after all, are credited with truly extraordinary power, bordering on the miraculous. A simple, inexpensive intervention can purportedly eliminate half of postoperative deaths.1 The supposed mechanism of this dramatic reduction in mortality is equally fantastic: ensuring that the team members, patient, and procedure are properly identified and confirming that the team has contemplated several processes of care. Such large effects seem implausible, especially considering that most of these processes were already required in modern hospitals and that none has been proved to reduce surgical mortality when applied individually.

Populations and subgroups

What kind of evidence supports the effectiveness of checklists? Principally, it comes from before-and-after studies,12 which have limited value in demonstrating causal effects because of their susceptibility to bias. Caution is always warranted when analyzing longitudinal trends in surgical safety, since operative mortality has been declining over time.3 The one published randomized study of checklists was a stepped wedge cluster randomized controlled trial, carried out in just two hospitals.4 That trial didn’t find a statistical reduction in postoperative mortality with the use of a checklist. It did find a reduction …

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